Communication and Documentation

Chapter Communication and Documentation Eleven

Chapter ,[object Object],[object Object],[object Object],[object Object],Eleven CORE CONCEPTS

[object Object],[object Object],understand. Interpersonal Communication Principles (Continued)

[object Object],[object Object],language. distinctly. Interpersonal Communication Principles (Continued)

Position yourself lower than patient.

[object Object],(Ask the patient what he/she wants to be called.) ,[object Object],manner. Interpersonal Communication Principles (Continued)

[object Object],time to answer each question. ,[object Object],[object Object],Interpersonal Communication Principles (Continued)

[object Object],or auditory deficits. ,[object Object],non-English-speaking persons. Interpersonal Communication Principles

Base Station Components of a Communication System (Continued)

Mobile Two-Way Radios Portable Radios (Continued)

[object Object],[object Object],[object Object],[object Object],Communication System Components and licensed by the Federal Communications Commission

[object Object],[object Object],medications/interventions. Communication with Medical Direction (Continued)

[object Object],the need for medications based on your report (be concise, accurate, and pertinent). (Continued) Communication with Medical Direction

After receiving an order: ,[object Object],word for word. ,[object Object],are unclear or appear to be inappropriate. Communication with Medical Direction

[object Object],[object Object],[object Object],[object Object],(Continued) Communication with Dispatch

[object Object],[object Object],[object Object],[object Object],Communication with Dispatch

[object Object],[object Object],one second before speaking. ,[object Object],(Continued) Communication Principles

[object Object],[object Object],the air. ,[object Object],information. Communication Principles

[object Object],to hospital. ,[object Object],[object Object],picture” of the patient with words. Radio Report

[object Object],[object Object],[object Object],[object Object],(Continued) Radio Report: Content

[object Object],present illness ,[object Object],[object Object],[object Object],(Continued) Radio Report: Content

[object Object],physical exam ,[object Object],[object Object],Radio Report: Content

[object Object],[object Object],the radio report. Verbal Communication at the Hospital radio report. ,[object Object]

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Prehospital Care Report: Functions

[object Object],an element. ,[object Object],established for a PCR (Continued) PCR Minimum Data Set

[object Object],for elements ,[object Object],(Continued) PCR Minimum Data Set

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Gathered at the time of the EMT-B’s initial contact with patient on arrival at scene, following all interventions, and on arrival at facility PCR Minimum Data Set Patient Information

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],PCR Minimum Data Set Administrative Information

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],PCR Narrative

Writing a good PCR is a skill that most people must practice to be good at. Instead of overwhelming new EMT-Bs with this task, introduce them to it gradually. On relatively simple calls at first, have new EMT-Bs write the form as you dictate it. As understanding grows, have them write out the narrative section on a blank piece of paper, not the PCR. This allows you to suggest corrections and improvements without worrying about neatness. As EMT-Bs gain more confidence, they can write on the PCR directly for more difficult calls. P RECEPTOR P EARL

[object Object],[object Object],PCR

[object Object],certification/license. ,[object Object],care. (Continued) Falsification of PCR

[object Object],[object Object],occurs, document what did or didn ’ t happen. Falsification of PCR

Correction of Errors on PCR ,[object Object],. ,[object Object],[object Object],line through the error. beside it. error. (Continued)

[object Object],[object Object],[object Object],[object Object],form is submitted: out. Correction of Errors on PCR

[object Object],may legally refuse treatment. ,[object Object],of the consequences of refusing care. (Continued) Patient Refusal

[object Object],accept care and transportation. ,[object Object],make an informed, rational decision. (Continued) Patient Refusal

[object Object],[object Object],[object Object],findings. (Continued) Patient Refusal

[object Object],convince patient to go to hospital. ,[object Object],protect patient after you leave. ,[object Object],necessary. Patient Refusal

[object Object],MCI complete a PCR ,[object Object],the scene. ,[object Object],documentation. Special Reporting Situations

[object Object],[object Object],[object Object],primary reports. Special Situation Reports

1. List the required elements of a radio report. 2. Describe ways to improve interpersonal communication. R EVIEW QUESTIONS

Communication and Documentation

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Communication and Documentation