Communication, Documentation

Pearson chapter 8 and 7, (chapter 41 EMT)

nonverbal vs verbal vs written vs visual communication

verbal: words
nonverbal: body language

written: letters and words
visual: signs/symbols with body

health care literacy

degree to which an individual has the ability to obtain, understand, and use health information and services to make appropriate health-related decisions.

continuity of care

Each provider who assumes care for a patient must be properly informed of the patient’s progression, so they can watch for trends and continue effective treatments.

Patient data

name, address, date of birth, gender, vital signs, anything that can identify patients

DOT

department of transportation

minimum data set

info required by US DOT for data collection on each patient

whats in minimum data set

• Time the incident was reported to 911

• Time of dispatch

• Time of arrival at the patient’s location

• Time the patient was transported from the incident location

• Time the patient arrived at the destination (hospital, aid station, etc.)

• Time the patient care was transferred to more advanced providers

• Patient’s chief complaint

• Patient’s approximate weight and vital signs

• Patient’s demographics (age, gender, race)

Shannon weaver communication model

1. sender has thought and wants to communicate it

2. sender encodes thought into message

3. sender transmits the message to receiver

4. receiver decodes message

5. receiver provides feedback

Job of lead provider

• Patient Assessment: Performs the primary and secondary physical assessments.

• Care Planning: Determines the treatment plan, makes the field diagnosis, and directs interventions.

• Interventions: Executes advanced skills (like intubation, IV access, or administering cardiac medications) if certified.

• Communication: Gives the radio report to the receiving hospital and speaks directly with online medical control if needed.

• Documentation: Completes the official Patient Care Report (PCR) detailing the incident.

• Transport Decision: Stays in the back of the ambulance with the patient during transport to monitor their condition.

Job of supporting provider

assisting primary provider, does vitals often and follows what told

Job of Driver/operator

Responsible for safely driving the ambulance and ensuring timely transport of the patient to the hospital. This includes navigation and communication with the medical team during transport.

close loop communication

1. send message (gives direct instruction)

2. repeat back (receiver repeats back to show they understood)

3. confirm accuracy (sender confirms or corrects receiver).

DMIST

how to do hand off reports

Demographics (name age gender)

Mechanism of injury or nature of illness

Injuries/illness identified

Signs and symptoms (vitals, symptoms)

Treatments (what you did and it’s affect)

DESC

Describe

Express

Suggest

Consequences

[used to express disagreement professionally]