Chapter 4: Communications and Documentation

Therapeutic Communication

Uses various strategies and techniques, both verbal and nonverbal, to encourage a patient to express how they are feeling and form positive relationships.

Factors and Strategies to Consider During Communcation

Age, body language, clothing, culture, education, environment, eye contact, facial expression, sex, posture, voice tempo, and volume.

How does culture affect body language and eye contact?

In some cultures, it is impolite to maintain eye contact while it is polite in others.

Ethnocentrism

Consider your own cultural values more important when you are interacting with people from other cultures.

Cultural Imposition

Forcing cultural values onto others.

Nonverbal Communication | How to Approach a Hostile Patient

1. Asses the safety of the scene.

2. Never assume an aggressive posture.

3. Make good eye contact, but do not stare.

4. Speak calmly, confidently, and slowly.

5. Never threaten the patient, either verbally or physically.

Noise

Anything that dampens or obscures the true meaning of a message.

Verbal Communication | Open-ended questions

The patient needs to provide some level of detail to give an answer

Verbal Communcation | Closed-ended questions

Can be answered in short or single-word responses.

Important for when a patient is unable to provide long or complete answers.

Facilitation

Encourage the patient to talk more or provide more information.

Pause

You do not speak.

Reflection

Restating a patient’s statement made to you to further your understanding.

Empathy

Be sensitive to the patient’s feelings and thoughts.

Clarification

Ask the patient to explain what he or she meant by an answer.

Confrontation

Make the patient who is in denial and in a mental state of shock focus on urgent and life-critical issues.

Interpretation

Restate the patient’s complaint to confirm your understanding.

Explanation

Provide factual information to support a conversation.

Summary

Provide a patient with an overview of the conversation and the steps you will take.

Interview Techniques to Avoid

1. Provide false hope or reassurance.

2. Give unsolicited advice.

3. Ask leading or biased questions.

4. Talk too much.

5. Interrupt the patient.

6. Use “why” questions.

7. Use authoritative language.

8. Speak in professional jargon.

The 10 Golden Rules to Help You Calm and Reassure Your Patient and Provide a Therapeutic Rapport

1. Make and keep eye contact with your patient.

2. Provide your name and use your patient’s proper name.

3. Tell the patient the truth.

4. Use language that the patient can understand.

5. Be careful what you say about the patient to others.

6. Be aware of your body language.

7. Speak slowly, clearly, and distinctly.

8. If the patient is hard of hearing, face the person so that he or she can read your lips.

9. Allow time for the patient to answer or respond to your questions.

10. Act in a calm, confident manner while caring for the patient.

Rapport

Building a trusting relationship with the patient

Emotional Intelligence

The ability to understand and manage your own emotions and properly respond to other’s emotions.

The Five Attributes of Emotional Intelligence

1. Self-awareness.

2. Self-regulation.

3. Motivation.

4. Empathy.

5. Social Skills

The Behavioral Change Stairway Model

1. Employ active listening.

2. Display empathy.

3. Build a rapport.

4. Exert influence.

Communicating With Older Patients

• Never assume a patient is senile or confused.

  • May be due to hypoxia, brain injury, unintentional drug overdose, infection, abnormal blood glucose levels, or perfusion.

• Patience and compassion

• Approach slowly and calmly

• Pack some of their personal belongings (include information in PCRs).

Communicating With Children

• Familiar faces reduce fright.

• Have a parent or guardian nearby.

• Be honest with children.

• Respect their modesty.

• Speak in a professional and friendly way.

• Maintain eye contact as you would with an adult.

Communicating With Patients Who Are Deaf or Hard of Hearing

1. Have paper and a pen available

2. If the patient can read lips and you need to remove your mask, have a clear barrier mask ready to use. You should face the patient and speak distinctly at a normal pace.

3. Never shout.

4. Be sure to listen carefully, ask short questions, and give short answers.

5. Learn some simple phrases in sign language.

Communicating With Visually Impaired Patients

• Ask if they can see.

• Tell them what you are doing in detail.

• Stay in physical contact.

• Guide patient with your arm.

• Transport eyeglasses and mobility aids.

• Bring guide dog if patient is stable and vice versa.

Communicating With Non-English-Speaking Patients

• How much English does the patient speak?

  • Use short and simple questions or point to specific parts of the body.

• Use a translation app if the patient does not speak English.

• Have a family member or friend translate.

• Request a translator at the hospital.

Mission-Critical Communications

Communications in which disruptions will result in the failure of the task at hand.T

The Mental Model

Allows teams to work efficiently, effectively, and error-free.

1. What is the focused priority for the patient?

2. What is the history of prior care?

3. What is the patient’s current state?

4. What are the patient’s immediate needs?

Patient Care Handover

Transfer of pertinent patient information and the responsibility for the patient’s care.

Described as “the most dangerous point in a patient’s ED journey.”

Giving the Handover Report

1. Initiate eye contact.

   • Helps identify handover is beginning.

2. Manage the environment.

   • Minimize noise, interruptions, and distractions.

3. Ensure the ABCs.

4. Provide a structured report.

   • Improves efficiency and reduces errors.

5. Provide documentation.

   • Priority care, prior care, current state, and immediate needs.

SBAR/SBAT

Structured format that stands for situation, background, assessment, and recap/Rx/treatment.

Receiving the Handover Report

1. Maintain eye contact.

2. Manage the environment.

   • Ask questions to clarify and correct any issues.

3. Ensure understanding.

4. Summarize.

5. Gather supplementary patient documentation

The Patient Care Report (PCR)

The legal document used to record all aspects of care your patient received, from initial dispatch to arrival at the hospital.

• Written or electronic (ePCR).

• Entered into a data pool such as NEMSIS.

• Contains a narrative section.

  • Time of events.

  • Assessment findings.

  • Emergency medical care provided.

  • Changes in the patient after treatment.

  • Observations at the scene.

  • Final patient disposition.

  • Refusal of care.

  • Staff person who continued care.

The 6 Functions of the PCR

1. Transfer of information and continuity of care.

2. Compliance and legal documentation.

3. Administrative information.

   • Patient billing and response times.

4. Reimbursement.

5. Education.

   • National trends.

6. Data collection for quality improvement and research.

   • Determine patterns of EMS response.

CHART Method

• Chief complaint.

  • States the condition most urgently requiring EMS intervention.

• History or physical examination.

  • Details relating to current event and the patient’s medical history.

• Assessment.

  • All assessments performed on patient.

• Treatment (Rx).

  • All interventions that were performed.

• Transport.

  • How the patient was moved to the ambulance; how they were positioned; sirens and lights on or off; where they were taken; and the person the report was transferred to.

SOAP Method

• Subjective.

  • Information provided by patient and others.

• Objective.

  • Details gathered through patient assessment.

• Assessment.

  • Summarize key findings.

• Plan.

  • Document treatment provided for the patient.

Medical Necessity

It would have been impossible or unsafe to transport the patient by any other means.

Health Information Exchange (HIE)

Improve sharing of data between EMS and other health care providers.

• Allow EMTs to contribute to and access electronic health information.

SAFR

• Search

  • Search records.

• Alert

  • Alerted of incoming patients and information entered.

• File

  • Stored in health records.

• Reconcile

  • Feedback on outcomes.

Reporting Errors

Write down what did or did not happen.

• Draw horizontal line through error, initial it, and write correct information next to it.

• Accidentally leave out information, write “addendum” in next section and write information, date, and initials.

Documenting Refusal of Care

Document patient assessment findings, emergency medical care given, efforts to obtain consent, and patient’s response.

• Discuss decision-making capacity.

• Discuss what care was recommended.

• Discuss consequences if they refuse.

• Discuss with bystanders to encourage patient.

• Discuss with medical direction according to protocol.

• Discuss alternatives.

• Willingness to return.

• Have the patient sign a refusal form.

• Have a bystander sign the form.

• Document whenever a patient refuses part of the standard treatment.

Special Reporting Situations

• Gunshot wounds, dog bites, infectious diseases, and suspected physical or sexual abuse.

• Mass casualty incidents (MCI)

Base Station

Any radio hardware containing a receiver and transmitter that is located in a fixed position.

• Dispatch centers, fire stations, ambulance bases, or hospitals.

Channel

Assigned frequency or frequencies used to carry voice and/or data communications.

Dedicated Line

Used for specific point-to-point contact.

• EMS personal are able to call the number directly without being placed on hold or transferred.

VHF (very high frequency) Mobile Radio

Operates between 30 and 300 MHz.

UHF (ultra-high frequency) Mobile Radio

Operates between 300 MHz and 3,000 MHz.

Portable Radios

Operates at 1 to 5 watts of power.

• Coordinate EMS activities at the scene of an MCI.

• Communicate with dispatch, another unit, or medical control.

Repeater

Receives messages and signals on one frequency and then automatically retransmits them on a second frequency.

• E.g. receive a low frequency and rebroadcast with greater power.

Digital Equipment

With telemetry, electronic signals are converted into coded, audible signals.

• These signals can then be transmitted by radio or telephone to a receiver with a decoder at the hospital.

Cellular Telephone

Low-power portable radios that communicate through a series of interconnected repeater stations called cells.

Satellite Phone

Uses a satellite.

Scanner

A radio receiver that searches or scans across several frequencies, stops whenever it receives a radio broadcast on that frequency, and continues once the message is complete.

Simplex

Push to talk, release to listen.

Duplex

Simultaneous talk-listen.

Multiplex

Utilizes two or more frequencies.

Trunking

Many frequencies are assigned to a group.

Interoperable Communications System

Allows all agencies involved to share valuable information with each other in real time.

Mobile Data Terminal (MDT)

A small computer terminal inside the ambulance that directly receives data from the dispatch center.

Federal Communications Commission (FCC)

The federal agency that has jurisdiction over interstate and international telephone and telegraph services and satellite communications, all of which may involve EMS activity.

The 5 Principle Responsibilities of the FCC

1. Allocate specific radio frequencies for use by EMS providers.

2. License base stations and assign appropriate radio call signs for those stations.

   • FCC license issued for 5 years; granted for a specific operating group.

3. Establish licensing standards and operating specifications for radio equipment used by EMS providers.

   • Radio equipment must be submitted to the FCC by its manufacturer for type acceptance.

4. Establish limitations for transmitter power output.

   • Regulates broadcasting power to limit interference.

5. Monitor radio operations.

The Dispatcher

• Properly screen and assign priority to each call

• Select and alert the appropriate EMS response unit or units

• Dispatch and direct EMS response unit or units to the correct location.

• Coordinate the EMS response unit or units with other public safety services until the incident is over.

• Provide emergency medical instructions to the telephone caller so that essential care may begin before the EMTs arrive.

Paging

The use of a radio signal and a voice or digital message that is transmitted to pagers (“beepers”) or desktop monitor radios.

How should you communicate with dispatch?

• Speak in plain English with no code words.

• Slow, relaxed, and clear tone.

• Avoid wordiness.

Communicating With Medical Control and Hospitals

Notify of an incoming patient, request advice or receive orders, or advise the hospital of special situations.

Giving the Patient Report

1. Your unit identification and level of services.

2. Any special “alert” indicated by the patient’s status or care.

3. The receiving hospital and your estimated time of arrival.

4. The patient’s age and sex.

5. The patient’s chief complaint or your chief concern regarding the patient’s problem and its severity.

6. A brief history of the patient’s current problem.

7. A brief report of the physical findings.

   • LOC, the patient’s general appearance, pertinent abnormalities noted, and vital signs.

8. A brief summary of the care given and any patient response.

9. A brief description of the patient’s response to the treatment provided.

10. Determine whether the receiving facility has any additional questions or orders.

The Role of Medical Control

Guides the treatment of patients in the system through protocols, direct orders, advice, and post-call review.

Calling Medical Control

• Use a radio in the unit, a portable radio, or a cellular telephone.

• Repeat order back, word for word, and receive confirmation.

• Respectfully question unclear orders.

Maintenance of Radio Equipment

• Serviced at least once per year.

• Check the ambulance to ensure it is ready to go.

• Have backup plans in the event that equipment fails.

Standing orders

Written documents, signed by the EMS system’s medical director, that outline specific directions, permissions, and sometimes prohibitions regarding patient care; also called protocols.