Communication and Documentation in Emergency Medical Services

PSAP

Public Safety Answering Point for emergency calls.

Base Station

Fixed communication point for radio systems.

Mobile Radio

Mounted in vehicles, 20-50 watts power.

Portable Radio

Handheld device with 1-5 watts power.

Repeater

Receives and retransmits radio signals.

VHF

Very High Frequency, better for long distances.

UHF

Ultra High Frequency, better for crowded areas.

Simplex

One frequency communication, e.g., pagers.

Duplex

Two voice frequencies, e.g., telephones.

Multiplex

Two voice and one data frequency system.

EMD

Emergency Medical Dispatcher, trained for emergencies.

CAD

Computer Assisted Dispatch for automatic entries.

County Numbering System

Systematic numbering for EMS and hospital contacts.

Emergency Communication

Use plain English, think before speaking.

ED Radio Report

Essential patient information for emergency departments.

HIPAA

Regulation ensuring patient information confidentiality.

Telemetry

Transmission of patient data like ECGs.

Interpersonal Communication Principles

Guidelines for effective patient interactions.

KISS Method

Keep It Simple and Straightforward.

Patient Information

Includes name, age, sex, and chief complaint.

Communication with Medical Direction

Consultation for major trauma and interventions.

Acknowledgement

Confirming receipt of information during communication.

Background Noise

Unwanted sounds that interfere with communication.

Mental Status

Patient's cognitive function and awareness.

Vital Signs

Key indicators of patient health status.

Hearing-Impaired

Individuals who have partial or total inability to hear.

Non-English Speaking Populations

Groups of people who do not speak English as their primary language.

Use of interpreters

Employing individuals who can translate spoken language to facilitate communication.

Very young or elderly patients

Patients who are either infants/children or older adults, often requiring special communication considerations.

Cultural differences

Variations in beliefs, values, and practices among different cultural groups.

Source/Sender

The individual or entity that initiates the communication process.

Encoding

The process of converting information into words, images, or signals.

Message

The information that is communicated from the sender to the receiver.

Channel

The pathway through which the message is transmitted.

Receiver/Decoder

The individual who interprets the message.

Feedback

The response provided by the receiver after interpreting the message.

Noise

Any interference that confuses or disrupts the communication process.

Facilitation

Encouraging the patient to express their thoughts and feelings.

Silence

Allowing the patient time to think and respond.

Reflection

Restating the patient's comments to show understanding.

Empathy

Being sensitive to the patient's feelings and experiences.

Clarification

Asking the patient to explain or elaborate on their statements.

Confrontation

Encouraging the patient to focus on specific questions or issues.

Interpretation

Summarizing the patient's complaint for clarity.

Explanation

Providing factual information to the patient.

Summary

An overview of the problems and treatments to be addressed.

Open-ended questions

Questions that allow for a wide range of responses, often used with adults.

Closed or direct questions

Questions that require specific answers, suitable for children or patients with impairments.

Interviewing Traps

Common pitfalls in patient interviews that can hinder effective communication.

PCR: Prehospital Care Report

A document that serves as a permanent hospital and medical record.

Continuity of Care

Ensuring that patient care is consistent and coordinated over time.

Legal document

A document that may be used in legal proceedings to verify care provided.

SOAP / SOAPIE Charting

A method of documentation that includes Subjective, Objective, Assessment, Plan of Action, Intervention, and Evaluation.

CHART Format

A documentation format that includes Chief complaint, history, assessment, treatment, and transport.

Pertinent positives

Symptoms patient complains about; factors related to symptoms

Pertinent negatives

Symptoms commonly associated with patient's potential problem that are not present or lack of associated factors

Billing info

Insurance, etc.

Quality assessment

Evaluation of the quality of care provided

Trend/staffing analysis

Analysis of trends in staffing and performance

Time standards for completion of documentation

Guidelines for how long documentation should take

Drop report/Transfer report

Provides a report prior to departing from the hospital - needs to contain minimum data set and a transfer signature prn

Types of documentation

Includes written format, computer-based PCR forms, and handheld devices for documentation

Characteristics of Good Documentation

Complete, Accurate, Precise, Timely, Legible/Correct spelling & terms, Unbiased, Unaltered unless done according to policy

Correction of Errors

Draw a single horizontal line through the error, write the correct information beside it & initial

Falsification of the PCR

Leads to poor patient care and may lead to revocation of certification

CONFIDENTIALITY

The PCR itself, and the information it contains, is strictly confidential!

PHI

Protected Health Information, which includes individually identifiable or demographic info

Examples of PHI

Name, Geographic identifiers smaller than a state, Dates, Phone/fax numbers, E-mail addresses, Medical record numbers, Certificate/license numbers, Health plan numbers

Multiple-Casualty Incidents (MCI)

Standard for completing documentation is not the same as for a typical call

Patient Refusal

Competent adult has the right to refuse care

Patient Refusal Documentation

Document all assessment findings & care needed & patient's refusal of assessment/care

Case Example - DeTarquino vs. the City of Jersey City (NJ)

A lawsuit against EMS providers for negligent documentation regarding a patient's vomiting

Word Parts

Terminology made of Latin & Greek words including Root Words, Prefixes, Suffixes, and Combining Forms

Root Words

The stem on which the term is based that conveys body system or part, disease process, or condition

Prefixes

Modifiers/Descriptors added to the front of a root word

Suffixes

Modifiers/Descriptors added to the end of a root word

Combining forms

Short combinations of letters usually vowels, used to connect two root words or a root word and a prefix

Pleurals

Many medical terms use Latin or Greek-based endings such as 'a', 'i', 'ies', etc.

Examples of Medical Terms

hematuria, pneumothorax, hypoglycemia, neuritis, quadriplegic