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105 Chapter 15

Communication and Documentation

TermDefinition
base stations two-way radios at a fixed site such as hospital/dispatch center
mobile radios two-way radios used or affixed in a vehicle. Lower wattage than base station
watt unit measure of output power of radios (20-50 watts for mobile radio, about 10-15 miles)
portable radios handheld two-way radios, output of 1-5 watts
repeaters devices used when transmissions must be carried over a distance
cell phones mainly for remote areas, when expense is too great to set up a conventional EMS system
telemetry the process of sending and receiving data wirelessly, some Electrocardiogram, vital signs, or other-patient data. might allow EMTs to transmit ECGs to hospital
in quarters the station or ambulance garage
FCC Federal Communications Commission, in charge of assigns and licenses radio frequencies
First 6 Steps of Radio Medical Report 1. Unit ID and level of provider 2. ETA 3. Patients age + sex 4. CC 5. Brief pertinent history of present illness 6. major past illness
Last 6 Steps of Radio Medical Report 7. Mental Status 8. Baseline Vital 9.Pertinent findings of phys. exam 10. Emergency medical care given 11. Response to the care 12. Contact with medical direction or "Questions?"
4 Guidelines when communication to MD 1. report information slowly, clearly, and accurately 2. Repeat order or denial back to confirm 3. Ask to repeat if necessary 4. If order seems inappropriate, question physician
Verbal Report at Hospital 1. CC 2. History not previously given 3. Additional treatment given en route 4. Additional Vital Signs taken en route
6 Therapeutic Communication Guidelines * eye contact * position and body language * use simple language * be honest * use patients proper name * listen
PCR Prehospital Care Report or trip sheet, run report etc.
drop/transfer report an abbreviated PCR left at hospital when the EMT doesn't have time to complete PCR before leaving hospital
Two Sections of PCR Run Data & Patient Information
Narrative Part of PCR *include objective and pertinent subjective, *include pertinent negatives *avoid radio codes and nonstandard abbrvs *write legibly * use med term correctly *if its not written down you didn't do it
Legal Issues of PCR Confidentiality (HIPAA) * Patient Refusals *Falsifications *Error Correction
2 type of Errors *Omission - part of assessment or care left out * Commission - actions performed on patient that are wrong or improper
Corrections of Errors With different color ink, draw a line through and initial + Date and add change, redistribute report according to protocol
MCIs Use TRIAGE TAGS (which contain CC, vital signs, and treatment given) to keep information of patient as he/she moves through the system
Created by: jon.kowalski
Popular Paramedic/EMT sets

 

 



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