Chapter 4: EMT Communications and Documentation Practice Flashcards

A comprehensive set of vocabulary flashcards covering effective communication, therapeutic techniques, cultural considerations, specialized patient interactions, documentation standards, and EMS communications equipment based on common EMT curriculum standards.

Communication

The transmission of information from one person to another which may be written, verbal, or nonverbal through body language.

Documentation

The written or electronically recorded portion of your patient care interaction that becomes part of the patient's permanent medical record.

NEMSIS

National Emergency Medical Services Information System; a data collection system that links prehospital records to hospital discharge outcomes for research and funding purposes.

Therapeutic communication

Uses various verbal and nonverbal techniques and strategies to encourage patients to express how they are feeling and allow the EMT to listen and understand.

Health literacy

The ability of the patient, their family, caregivers, or bystanders to understand and process health information.

Iatrophobia

The clinical term for medical fear, or the fear of medicine and medical workers.

Ethnocentrism

Occurs when you consider your own cultural values as more important when you are interacting with people of a different culture.

Cultural humility

The practice of being curious about others and keeping an open mind when interacting with people from unfamiliar cultures to reflect and learn from those experiences.

Unconscious bias

Also referred to as implicit bias; a condition where individuals have natural biases but are often unaware of how these biases affect their interactions with others.

Cultural imposition

Occurs when health care clinicians consciously or subconsciously force their cultural values onto their patient because they believe their values are better.

STAMP

A mnemonic used to remember signs that a patient may become an aggressor: Staring, Tone of voice, Anxiety, Mumbling, and Pacing.

Noise

Anything that makes it difficult to understand the meaning of a message, including literal sounds, lighting, distance, or physical obstacles.

Open-ended questions

Questions in which a patient needs to provide some level of detail to give an answer; used to allow a free flow of conversation.

Closed-ended questions

Questions that can be answered in short or single-word responses like "yes" or "no"; useful when patients are unable to provide long answers.

Facilitation

A therapeutic communication technique used to encourage the patient to talk more or provide more information.

Reflection

A therapeutic communication technique involving restating a patient's statement made to you to confirm your understanding.

Emotional intelligence

The ability to understand and manage your own emotions and properly respond to others' emotions, often referred to as "people skills."

Behavioral change stairway model

A five-step crisis communication model developed by the FBI involving active listening, empathy, rapport, influence, and behavior change.

Person-first language

A communication approach that describes a person before their condition (e.g., "patient with diabetes" instead of "diabetic") to improve clinical relationships.

Functional age

A classification that relates to a person's ability to function in daily activities, mental state, and health status, rather than their chronological age.

Family-centered care

A healthcare approach where patients and stakeholders (like family) are treated with respect and inclusion to improve quality of care and reduce errors.

Shared mental model

A picture that team members have in their heads of what is going on; the goal of mission-critical communications is the efficient transfer of this model.

Patient care handoff

Also called handover; the transfer of pertinent patient information and the responsibility for the patient's care between health care professionals.

SBAT

An EMS version of the SBAR format for structured reports, standing for Situation, Background, Assessment, and Treatment.

Stages of grief

A theory by Dr. Elisabeth Kübler-Ross identifying five stages people go through: Denial, Anger, Hostility, Bargaining, Depression, and Acceptance.

GRIEVING

A structured notification process for conveying news of death: Gather, Resources, Identify, Educate, Verify, [Space], Inquire, Nuts and bolts, and Give.

Patient care report (PCR)

A legal document used to record all aspects of the care a patient received from initial dispatch to arrival at the hospital.

Minimum data set

A set of uniform components identified by NEMSIS to enable communication and comparison of EMS runs between agencies and states.

Military time

A time-keeping system used in EMS documentation where each hour is unique (0000–2300) and spoken in "hundred hours."

Medically necessary

A standard required by Medicare and Medicaid for reimbursement, meaning it would have been unsafe or impossible to transport the patient by any other means.

Health information exchange (HIE)

Also known as a health data exchange (HDE); a system to improve the sharing of data between EMS and other health care clinicians.

SAFR

A framework for health information exchanges: Search (for records), Alert (hospitals), File (incorporate data), and Reconcile (feedback on outcomes).

Addendum

A new section added to a completed handwritten or electronic report to include information that was accidentally left out or to correct an error.

CHART

A standardized narrative format: Chief complaint, History, Assessments, Treatment (Rx), and Transport.

SOAP

A standardized narrative format: Subjective, Objective, Assessment, and Plan.

Base station

Any radio hardware containing a transmitter and receiver that is located in a fixed place, such as a dispatch center or hospital.

Channel

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

Dedicated line

Also known as a hotline; used for specific point-to-point contact between EMS personnel and an emergency department to record medical command conversations.

Repeater

A special base station radio that receives messages on one frequency and automatically retransmits them on a second frequency at higher power.

Telemetry

A process where electronic signals are converted into coded audible signals for transmission by radio or telephone to a receiver with a decoder at a hospital.

Simplex

A radio mode where transmissions can occur in either direction but not simultaneously (push to talk, release to listen).

Duplex

A radio mode where communications utilize paired frequencies to allow simultaneous talk and listen capabilities.

Multiplex

A communications design utilizing two or more frequencies to enable more than one transmission to occur simultaneously for both audio and data signals.

Trunking

A radio system where many frequencies are assigned to a group and a computer constantly monitors frequency load to reassign transmissions to unused frequencies.

Interoperable communications system

A system using voice-over-Internet protocol (VoIP) to allow multiple agencies to share information in real time across landlines, cell phones, and computers.

Mobile data terminal (MDT)

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

Federal Communications Commission (FCC)

The federal agency that regulates all radio operations in the United States, including allocating frequencies and licensing base stations for EMS.

Standing orders

Written documents signed by the medical director that outline specific directions and permissions for patient care without requiring direct communication with medical direction.

Factors and Strategies for Therapeutic Communication with Patients

Factors include the patient's emotional state, cultural background, and health literacy; strategies include using open-ended questions, showing empathy, and giving time for the patient to express themselves.

Techniques for Effective Verbal Communication

Techniques include active listening, reflecting back patient statements, using clear language, and avoiding jargon.

Special Considerations in Communication

For older patients: use clear speech and be patient. For children: use age-appropriate language. For hearing impaired: face the patient and use sign language if needed. For visually impaired: provide verbal cues. For non-English speakers: use interpreters.

Communication Skills for Family and Others

Skills include active listening, empathy, clarity, and sensitivity to emotions.

Issues in Care of the Dying

Consider patient end-of-life wishes, provide emotional support, and understand grief stages: denial, anger, bargaining, depression, acceptance.

Physiological and Psychological Responses to Stress

Stress may cause increased heart rate, anxiety, irritability, physiological changes like sweating, and psychological responses such as depression.

Use of Written Communications and Documentation

Ensures accurate, permanent records of patient interactions for continuity of care and legal protection.

Purpose of a Patient Care Report (PCR)

Documents all aspects of patient care; includes patient's condition, treatment rendered, and transport details.

Legal Implications of the PCR

PCRs are legal documents and must be accurate and complete to protect against litigation.

Documenting Refusal of Care

Document the conversation, ensure the patient understands consequences, and have them sign a refusal form; legal implications involve liability.

State or Local Reporting Requirements

Certain cases, like gunshot wounds and abuse, require mandatory reporting to authorities as per laws.

Basic Principles of EMS Communication Equipment

Types include radios, mobile data terminals; principles involve understanding frequencies and maintaining clear communication.

Radio Communication Use

Identify yourself at the start, speak clearly, and conclude with acknowledgment following emergency protocols.

Communication Procedures in Call Phases

Gather details in initial receipt, communicate progress en route, notify on arrival, and confirm handoff and updates.

Patient Report Communication Sequence

Include demographics, chief complaint, history, findings, treatment, and transport information.

Techniques for Successful Cross-Cultural Communication

Be open-minded, respectful, aware of cultural differences, and patient.

Demonstration of PCR Completion

Accurately fill out demographics, nature of emergency, treatments, and patient responses.

Simulated Radio Transmission

Clearly state unit number, location, and request nature, concluding with acknowledgment.