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COMMUNICATION AND DOCUMENTATION (COMMUNICATION (VERBAL (Open-Ended…
COMMUNICATION AND DOCUMENTATION
COMMUNICATION
The passing of information form one person to another
THERAPEUTIC COMMUNICATION
Various communication techniques and strategies, verbal/nonverbal, to encourage patients to express how they are feeling and to achieve a positive relationship with the patient
NONVERBAL
Facial expressions, body language, and eye contact
VERBAL
Open-Ended Questions
Detail oriented questions
Close-Ended Questions
Questions that beget short, single-worded answers
COMMUNICATING WITH OLDER PATIENTS
Do not assume older patients are senile or confused
Do not assume hostility, irritability, and confusion are normal
NEVER attribute AMS to old age
May be have impaired hearing or vision
COMMUNICATING WITH CHILDREN
Children may be frightened; keeping familiar faces around will help reduce the first and anxiety
Be honest at all times
Respect a child's modesty
Speak to children in a professional manner
COMMUNICATING WITH DEAF/HARD OF HEARING PATIENTS
Have a paper and pen available just in case the patient has trouble reading lips
Never shout; speak slowly
Ask short questions
Learn simple ASL phrases
COMMUNICATING WITH VISUALLY IMPAIRED PATIENTS
Ask the patient whether they can see at all
Stay in physical contact with the patient
COMMUNICATING WITH OTHER HEALTH CARE PROFESSIONALS
Opening, pertinent patient information
Giving detailed information that was not given during radio report
Any pertinent patient history
Patient's response to given treatments
Vitals signs in transit
DOCUMENTATION
Written or electronic recorded portion of the patient care interaction that becomes part of the patient's permanent medical record
PATIENT CARE REPORT
Also known as a PCR. This document helps ensure efficiency of continuity of care for the patient. PCRs describe nature of patient's injuries/illness at the scene and the initial treatment provided
PCRs have 6 main functions:
Continuity of Care
Legal documentation
Education
Administrative information
Essential research record
Evaluation and continuous quality improvement
DOCUMENTING REFUSAL OF CARE
Document any and all patient assessment findings
Document emergency medical care given
Document your efforts to obtain consent
Document the patient's response to your efforts