Chapter 4 (Communications and Documentation)

Question 1

Personal Space Distances

Answer 1

Intimate: Less than 18in

Personal: 18in - 4ft (convo with friends and family)

Social: 4ft - 10ft (Conversation with acquaintances)

Public: 10ft - 25ft (Strangers)

Question 2

Facilitation

Answer 2

Encourage the patient to talk more or provide more information

Question 3

Pause

Answer 3

Do Not Speak (give patient time to think and respond)

Question 4

Reflection

Answer 4

Restating what the patient said to confirm your understanding

Question 5

Empathy

Answer 5

Be sensitive to patients’ feelings and thoughts

Question 6

Clarification

Answer 6

Ask patient to explain what they meant by an answer

Question 7

Confromtation

Answer 7

Make the patient who is in denial or mental shock to focus on urgent and life critical issues

Question 8

Interpretation

Answer 8

Restate the patients complaint to confirm your understanding

Question 9

Explanation

Answer 9

Provide factual information to support the conversation

Question 10

Summary

Answer 10

Provide patient with an overview of conversations and steps you will take

Question 11

10 Golden Rules

Answer 11

1. Make eye contact
2. Provide name and use patients name back
3. Tell patients the truth
4. Use language patient can understand
5. Be careful what you say about the patient to others
6. Be aware of body language
7. Speak slowly, clearly, and distinctly
8. If patient hard of hearing, face them so they can read lips
9. Allow time for patient to answer of respond
10. Act and Speak in calm confident manner

Question 12

Mental Model (Whats going on (team))

Answer 12

1. What is the focused priority for the patient
   (what is the main issue of the problem)
2. What is the history of the prior care?
   (what got us to this point)
3. What is the patients current state?
   (Why are we here right now)
4. What are the patients immediate needs?
   (What is the next thing that needs to happen)

Question 13

PCR (Patient Care Report) Should Include

Answer 13

Chief complaint
Mechanism of injury or nature of illness
LOC (AVPU)
Vital Signs
Initial and ongoing assessment
Patient demographics (age, sex, ethnic background)
Transport information (How patient was moved, reason for destination choice)

Question 14

SBAT

Answer 14

S- Situation
(A concise statement of the problem)

B- Background
(Relevant, brief information about patient situation)

A- Assessment
(Assessment of your findings and what you think)

T- Treatment
(Care that has been provided to the patient)

SBAR:

Situation
Background
Assessment
Recap/Rx

Question 15

PCR Components

Answer 15

Patient info
Dispatched time and nature of call
Chief complaint
Location of patient when first seen
Rescue and treatment given before arrival
Signs and symptoms found during patient assessment
Care and treatment given by you
Response to treatment
Vitals
SAMPLE (signs, allergies,medications,past medical history,last intake,event leading up)
Changes in vitals or LOC
Additional orders received from hospital
Name of person receiving patient report
Date of call
Time of call
Location of call
Time of dispatch
Time of arrival at scene
Time of arrival at hospital
Patients insurance info
Names of EMTs who responded to call
Name of transport destination
Type of run to scene: emergency or routine

Question 16

CHART

Answer 16

Chief Complaint
History
Assessments
Treatments (Rx)
Transport

Question 17

SOAP

Answer 17

To structure documentation of the narrative.

Subjective
Objective
Assessment
Plan

Question 18

PCR Narratives should include

Answer 18

SOAP or other (check Pg 139-140)

Time of events
Assessment findings (physical exam, vitals)
Emergency Medical Care provided
Changes in patient after treatment
Observations at scene
Final patient disposition
Refusal of care
Staff person who continued care

Question 19

Health Information Exchange (HIE) Follow SAFR

Answer 19

Search (Seach for hopsital and other records)
Alert (Hospitals are alerted of incoming EMS patients)
File (Data incorporated directly into patients health records)
Reconcile (Feedback and outcomes and other hospital data are provided to EMS)