Patel 1 Tanvi Patel Ms.Alogna EMR / 45B 9/22/11 Chapter 4 Communication and Documentation Key Terms 1.

. Base Station powerful two way radio thats permanently mounted in a communications center 2. Repeaters radio system that automatically retransmits a radio signal on a different frequency 3. Run Data 4. Confidentiality patients right to make sure that none of their information is given to anyone but medical personnel, without their knowledge 5. Telemetry process where electronic signals are transmitted and received by radio or telephone; commonly used for sending ECG tracings 6. Mobile Radios two-way radio that is permanently mounted in a vehicle such as a car a police car or fire truck 7. Cellular Phones - help EMRs communicate with dispatch, when needed 8. Patient Information information that is needed about the patient for documentation and to provide proper medical care 9. Refusal the patients right to refuse care before or during care 10. Portable Radios hand-held, battery operated, two-way radio 11. PCR Patient Care Report Recording all the actions you perform for or on the patient 12. Narrative Personal account of what happened 13. Patient Hand-Off when paramedics or EMTs arrive, give them a hand-off report. Objective 1. Effective verbal communication is important because it can be the difference between life or death or a patient. Getting information to the EMTs, Paramedics, and hospital is important so they know what equipment they will need for effective treatment. This also saves time, and time is precious with injured patients. 2. The EMS radio system is made up of a base station, mobile radio, and portable radio. A repeater is used to amplify weak radio signals 3. While using a radio, follow these procedures, monitor the channel before transmitting, plan your message before pushing the transmit switch, press the PTT button and then wait for 1 second before starting your message, acknowledge a transmission as soon as you can, use plain English and avoid confusing words, dont voice negative emotions or profanity, and reduce background noise as much as possible. 4. You should make sure to tell medical direction the location of the incident, number of patients, type of incident, hazards, and the assistance, if any, you require. Also make sure to tell them, the age and gender of the patient, the chief complaint, level of responsiveness, status of the patients airway, breathing, circulation, and what equipment will be needed. 5. While interacting with a patient it is important to, introduce yourself, ask their name and to use it, make and keep eye contact, use language the patient can understand, speak slowly, clearly, and distinctly. Also make sure to tell the truth, allow time for the patient to respond, be aware of your body language, act and speak in a calm and confident manner, respect

Patel 2 cultural norms of all the patients, and most importantly treat all patients like your family members. 6. A written report should have, the age and sex of a patient, the history of the incident, the condition of the patient when found, description of injury or illness, chief complaint, level of responsiveness, initial and subsequent signs, results of physical exam, treatment you gave, any change after treatment, the agency of personnel who took over treatment, time you were dispatched, when you arrived and when other personnel arrived at scene, time you departed scene, any of the reportable conditions present, anything unusual, and helpful facts. 7. A written report is the basis for legal procedures. If you dont write something in your report, it doesnt matter that you did it, only what is on the report will be believed as true. If you do not document or record correctly, you may face legal action. Assessment in Action D B C A C D A You should let the patient know that you are a EMR and tell them your name. Dispatch, Response to the scene, Arrival at the scene, Update responding EMS units, Transferring the care of patient to other personnel, Post run activities. 10. Let the child have familiar objects of faces around, be friendly and stand at their level. Also you should use their parents to help assure the patient. 1. 2. 3. 4. 5. 6. 7. 8. 9. Story Ok, lets get one thing straight, I dont repeat myself and there will be a test after this part of your orientation. Got it? Good, announced the orientation leader. Wow she seems tough, whispered one of the new EMR recruits to her friend. The room to your left is the base station, the radio that permanently stays here is kept in that room. There are a few other rooms but none of you will be spending any time here. Then why are we even here? whines a young man. You wont be using a fax machine in the field but does that stop them from teaching you how to work it? No, learn to stop questioning and just doing as you are told. Yes mam mumbles the young man. Alright then, we are now going to go outside and look at the vehicles. Can anyone tell me what process allows radio signals to be transmitted and received? The recruits just keep walking, no one saying anything. No one? Its true the new ones get dumber and dumber every year. Well, I think its called telemetry, a quiet voice hesitantly says. Exactly, who is that? Step forward. The young boy steps forward and looks at the ground, clearly embarrassed. Come here, you get to do the demonstration today. Ummm yes mam. They have all reached the emergency vehicle now. Go ahead and grab the mobile radio. Press the button on the corner and speak into it. He does so and mimics a report to communications center about a patients condition. Great job, clearly you would be an asset on any team. Now go ahead and turn on the MDT, I mean Mobile Data Terminal. This will help you send and receive information from the communications system.

Patel 3 These are especially useful for sending reports of tests done on scene. Ok now lets head back in and this time lets see who can tell me what a repeater does. A repeater automatically retransmits a radio signal on a different frequency to help communicate even in dead spots. A very eager voice announces. Very good, and who is that? My name is Angel. Very good Angel, come here you will get to use the portable radio, show your colleagues how to use it. Angel speaks into the radio and gives a detailed patient hand-off report. Great now get into that room and take out a pen and paper. We are going to start the test. If you fail you keep doing this orientation until you pass.