Chapter 4: Communications and Documentation

Key Topics Covered

• Therapeutic Communication
• Effective Communication with Special Populations
• Effective Communication Methods and Procedures
• Components and Types of Effective Written Reports
• Correcting Errors in Written Reports
• Documentation of Refusal of Care
• Special Reporting Situations
• Medical Terminology
• Communication Systems and Equipment
• Radio Communication Regulations and Protocols
• Communication with Medical Control and Hospitals

Introduction

• Communication: Transmission of information verbally or through body language
• Effective Communication: Essential for pre-hospital care and positive relationships with patients and co-workers
• Documentation: Written or electronic record of patient’s medical history and care
  • Ensures continuity of care
  • Ensures proper transfer of responsibility
  • Compliance with health department and law enforcement requirements

Therapeutic Communication

• Definition: Techniques and strategies both verbal and non-verbal to create positive patient relationships
• Shannon-Weaver Communication Model:
  • Sender encodes a thought into a message
  • Receiver decodes the message and sends feedback to the sender
• Factors in Communication: Age, eye contact, body language, culture, etc.

Cultural Considerations

• Ethnocentrism: Believing your cultural values are superior
• Cultural Imposition: Forcing your cultural beliefs on others

Non-verbal Communication

• Body Language: Provides more information than words alone
• Physical Factors: Noise, proximity, gestures, etc.

Verbal Communication

• Open-ended Questions: Require detailed responses
• Close-ended Questions: Require short, specific answers
• Communication Tools: Facilitation, pause, reflection, empathy, etc.
• Interview Techniques to Avoid: False reassurance, unsolicited advice, leading questions, etc.
• Consideration for Family and Bystanders: Balance their presence and input with the patient's needs

Emotional Intelligence

• Definition: Ability to understand and manage emotions, build rapport, and manage difficult situations
• Attributes: Self-awareness, self-regulation, motivation, empathy, social skills

Special Patient Communication

• Older Patients: Don’t assume confusion; look for underlying conditions, be patient
• Children: Address fears, be honest, use simple language, etc.
• Hearing Impaired: Use visual aids, speak clearly, know basic sign language
• Visually Impaired: Explain actions, maintain physical contact, consider guide dogs
• Non-English Speaking: Use translators, simple language, learn basic phrases

Mission Critical Communications

• Shared Mental Model: Align team understanding on patient’s condition and needs
• Patient Care Handover: Effective transfer of patient information to receiving facility
  • Use formal methods like SBAR (Situation, Background, Assessment, Recap of Treatment)

Written Documentation

• PCR (Patient Care Report): Legal document recording care from dispatch to hospital
• Six Functions of PCR: Continuity of care, compliance, administration, reimbursement, education, data collection
• Standard Narrative Formats:
  • CHART: Chief Complaint, History, Assessment, Rx (Treatment), Transport
  • SOAP: Subjective, Objective, Assessment, Plan
• Error Correction: Use single line cross-through, initial, and correct information
• Refusal of Care Documentation: Detailed recording of the patient’s decision and EMS attempts to provide care

Special Reporting Situations

• Examples: Gunshot wounds, dog bites, infectious diseases, suspected abuse or MCIs

Communication Systems and Equipment

• Radio and Telecommunication: Essential for coordination in EMS, fire, and law enforcement
• Types of Radios:
  • Base Station: Fixed location transmitter/receiver
  • Mobile Radio: In-vehicle radio
  • Portable Radio: Handheld
  • Repeater-Based Systems: Enhance communication range
• Digital Equipment: Telemetry, cellular/satellite phones, etc.
• Mobile Data Terminals: For dispatch and in-ambulance digital communication

FCC Regulations

• FCC: Governs radio operations in the U.S.
  • Allocates frequencies, licenses stations, establishes standards, monitors operations

Scene and Medical Control Communication

• Dispatcher's Role: Receive and prioritize calls, provide pre-arrival instructions
• EMT Responsibilities: Communicate effectively upon arrival at scene
• Medical Control Communications: Notify hospital of incoming patient, request advice/orders

Special Situations Communication

• MCI and Hazardous Materials: Early notification for hospital preparation
• Maintaining Radio Equipment: Regular checks, backup plans
• Standing Orders: Written protocols with legal authority similar to direct orders