1 Communications and Documentation

COMMUNICATIONS AND DOCUMENTATION
Essential components of pre-hospital care:
 Verbal communications are vital.

 Adequate reporting and accurate records ensure continuity of patient care.
 Reporting and record keeping are essential aspects of patient care.
DISPATCH RESPONSIBILITIES
 Screen and assign priorities

 Select and alert appropriate units to respond
 Dispatch and direct units to the location
 Coordinate response with other agencies
 Provide pre-arrival instructions to the caller
INFORMATION RECEIVED FROM DISPATCH
 Nature and severity of injury, illness or incident

 Location of incident
 Number of patients
 Responses by other agencies
 Special information
 Time dispatched
COMMUNICATING WITH DISPATCH
 Report any problems during run.

 Advise of arrival
 Communicate scene size-up
 Keep communications brief.
COMMUNICATING WITH MEDICAL CONTROL
 Radio communications facilitate contact between providers and medical control.

 Consult with medical control to:
 Notify hospital of incoming patient.
 Request advice or orders.
 Advise hospital of special circumstances.
 Organize your thoughts before transmitting.
PATIENT REPORT
 Identification and level of services
 Receiving hospital and ETA
 Patient’s age and gender
 Chief complaint
 History of current problem
 Physical findings
 Summary of care given and patient response
ROLE OF MEDICAL CONTROL

 May be off-line or online
 Guides treatment of patients
 May have to contact directly for orders
 Many variations from system to system
EMR TRAINING
• Physician bases his or her instructions on report received from the EMT-B.
• Never use codes while communicating.
• Repeat all orders received.
• Do not blindly follow an order that does not make sense to you.
• Notify as early as possible
• Estimate the potential number of patients.
• Identify special needs.
• Keep transmission brief.
• Develop effective radio discipline.
• Identify the called unit, followed by the calling. –“Dispatch, this is Medic One.”
• Acknowledge dispatch information.
• Notify arrival at scene.
• Notify departure from scene.
• Notify arrival at hospital or facility
• Notify you are clear of the incident.
• Notify arrival back in quarters.
• Radio equipment must be properly serviced.
• Non-functioning equipment should be removed from service.
• Backup plans should be in place in case of communication failure.
• Standing orders: Written documents signed by the EMS system’s medical director.
• Essential part of quality patient care.
• You must be able to find out what the patient needs and then tell others.
• You are a vital link between the patient and the health care team.
• Patient’s name, chief complaint, nature of illness, mechanism of injury
• Summary of information from radio report
• Any important history not given earlier
• Patient’s response to treatment
• The vital signs assessed
• Any other helpful information
• Make and keep eye contact.
• Use the patient’s proper name.
• Tell the patient the truth.
• Use language the patient can understand.
• Be careful of what you say about the patient to others.
• Be aware of your body language.
• Always speak slowly, clearly and distinctly.
• If the patient is hearing impaired, speak clearly and face him or her.
• Allow time for the patient to answer questions.
• Act and speak in a calm, confident manner.
• Determine the person’s functional age.
• Do not assume that an older patient is senile or confused.
• Allow patient ample time to respond.
• Watch for confusion, anxiety, or impaired hearing or vision.
• Explain what is being done and why.
• Children are aware of what is going on.
• Allow people or objects that provide comfort to remain close.
• Explain procedures to children truthfully.
• Position yourself on their level.
IMPAIRED PATIENTS
 Always assume that the patient has normal intelligence.
 Make sure you have a paper and pen.
 Face the patient and speak slowly, clearly and distinctly.
 Never shout!
 Learn simple phrases used in sign language.
 Ask the patient if he or she can see at all.
 Explain all procedures as they are being performed.
 If a guide dog is present, transport it also, if possible.
SPEAKING PATIENTS
 Use short, simple questions and answers.
 Point to specific parts of the body as you ask questions.
 Learn common words and phrases in the non-English languages used in your area.
CARE REPORT
 Pre-hospital care report serves six functions:
 Continuity of care
 Legal documentation
 Education
 Administrative
 Research
 Evaluation and quality improvement
 Written forms
 Computerized versions
 Narrative sections of the form
 Use only standard abbreviations.
 Spell correctly
 Record time with assessment findings.
 Report is considered confidential.
 Do not write false statements on report.
 If error made on report then:
 Draw a single horizontal line through error.
 Initial and date error.
 Write the correct information
 Document assessment findings and care given.
 Have the patient sign then form.
 Have a witness sign the form.
 Include a statement that you explained the possible consequences of refusing care to the
patient.
 Be familiar with required reporting in your jurisdiction, including:
 Gunshot wounds
 Animal bites
 Certain infectious diseases
 Suspected physical,sexual or substance abuse
 Multiple-casualty incidents (MCI)
1. Dispose of all contaminated supplies (bandages, dressings, disposable materials) in a sealed

plastic bag.
2. Collect all contaminated reusable equipment and seal them in another plastic bag.
3. Clean the floor, walls and ceiling with soap and water. They may be contaminated with
blood, vomitus, faecal matter, dust, mud, etc.
4. Disinfect surfaces with a solution of water and 10 percent bleach. This solution may be
harmful to bright metal surfaces.
5. Air out the ambulance.
1. Remove the contaminated sheet.

2. Clean and disinfect stretcher mattress.
3. Turn the mattress.
4. Place a clean sheet on the mattress.
1. Scrub contaminated instruments to eliminate any dried-on material, then wash them
with soap and water.
2. Soak instruments in a 10% bleach and water solution for 10 minutes, then dry them off.
3. Replace instruments and any medication on the unit.
Items after every incident:
• Hands: Thoroughly wash hands in soap and water. Pay close attention to the fingernails.
• Clothes: Change out of any contaminated clothing and immediately wash separately from other
linens. Keep a spare change of clothes available.
• Shoes: Wipe shoes clean. Wash off all bodily fluids with a 10% bleach solution.

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COMMUNICATIONS AND DOCUMENTATION

Essential components of pre-hospital care:

 Verbal communications are vital.

 Screen and assign priorities

INFORMATION RECEIVED FROM DISPATCH

 Nature and severity of injury, illness or incident

COMMUNICATING WITH DISPATCH

 Report any problems during run.

COMMUNICATING WITH MEDICAL CONTROL

 Radio communications facilitate contact between providers and medical control.

ROLE OF MEDICAL CONTROL

1. Dispose of all contaminated supplies (bandages, dressings, disposable materials) in a sealed

1. Remove the contaminated sheet.

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