communication, documentation, history taking

Communication,

Documentation, History

TakingPrepared by Odane P. Hamilton, EMT

Sept. 2015

Introduction (1 of 2)

Communication is the transmission of information to another person.

Verbal

Nonverbal (through body language)

Verbal communication skills are important for the EMS system.

Enable you to gather critical information, coordinate with other responders, and interact with other health care professionals

Introduction (2 of 2)

Documentation

Patient’s permanent medical record

Demonstrates appropriate care was delivered

Helps others in patient’s future care

Complete patient records

Guarantee proper transfer of responsibility

Comply with requirements of health departments and

law enforcement agencies

Fulfill your organization’s administrative needs

Communication

Uses various communication techniques and strategies:

Both verbal and nonverbal

Encourages patients to express how they feel

Achieves a positive relationship with patient

Communication

Communication model

Sender takes a thought

Encodes it into a message

Sends the message to receiver

Receiver decodes the message

Sends feedback to the sender

Communication

Communication

Communication

Age, Culture, and Personal Experience

Shape how a person communicates

Body language and eye contact greatly affected by

culture

In some cultures, direct eye contact is impolite.

In other cultures, it is impolite to look away while

speaking.

Communication

Age, Culture and Personal Experience (cont’d)

Tone, pace, and volume of language

Reflect mood of person and perceived importance of

message

Ethnocentrism: Considering your own cultural values more

important than those of others

Cultural imposition: Forcing your values onto others

Communication

Non-verbal Communication

Body language provides more information than words

alone.

Facial expressions, body language, and eye contact are

physical cues.

Help people understand messages being sent

Communication

Non-verbal Communication (cont’d)

Physical factors

Noise: Anything that dampens or obscures true meaning

of message

Proxemics: Study of space and how distance between

people affects communication

Communication

Verbal Communication

Asking questions is a fundamental aspect of prehospital

care.

Open-ended questions require some level of detail.

Use whenever possible.

Example: “What seems to be bothering you?”

Communication

Verbal Communication (cont’d)

Closed-ended questions can be answered in very short

responses.

Response is sometimes a single word.

Use if patients cannot provide long answers.

Example: “Are you having trouble breathing?”

Communication

Communication Tools

There are many powerful

communication tools that

EMRs can use:

Facilitation

Silence

Reflection

Empathy

Clarification

Confrontation

Interpretation

Explanation

Summary

Communication

Interviewing Techniques

When interviewing a patient, consider using touch to show

caring and compassion.

Use consciously and sparingly.

Avoid touching the torso, chest, and face.

Communication

Interviewing Techniques (cont’d)

Golden Rules to help calm and reassure patient:

Make and keep eye contact at all times.

Provide your name and use patient’s proper name.

Tell patient the truth.

Communication

Interviewing Techniques (cont’d)

Use language the patient can understand.

Be careful what you say about patient to others.

Be aware of your body language.

Speak slowly, clearly, and distinctly.

Communication

Interviewing Techniques (cont’d)

For the hearing-impaired patient, face patient so he or

she can read your lips.

Allow the patient time to answer or respond.

Act and speak in a calm, confident manner.

Communication

Communicating with the Visually Impaired

Ask the patient if he or she can see at all.

Visually impaired patients are not necessarily

completely blind.

Expect your patient to have normal intelligence.

Communication

Communicating with the Visually Impaired (cont’d)

Explain everything you are doing as you are doing it.

Stay in physical contact with patient as you begin your

care.

If patient can walk to ambulance, place his or her hand on

your arm.

Transport mobility aids such as cane with patient to

hospital

Documentation

Patient care report (PCR)

Also known as prehospital care report

Legal document

Records all care from dispatch to hospital arrival

Documentation

The PCR serves six main functions:

Continuity of care

Legal documentation

Education

Administrative information

Essential research record

Evaluation and continuous quality improvement

Documentation

Information collected on the

PCR includes:

Chief complaint

Level of consciousness or

mental status

Vital signs

Initial assessment

Patient demographics

Time of events

Assessment findings

Emergency medical care provided

Changes in patient after treatment

Observations at the scene

Final patient disposition

Refusal of care

Staff person who continued care

WHAT IS A PATIENT’S HISTORY?

WHY ARE PATIENT HISTORIES

IMPORTANT?

Patient History

Accurate collection of information which

helps with assessment and management of

patient

Should ideally come from patient directly

May include, but not limited to, the

following:

Demographics (name, age, address,

contact number)

What happened to patient, when did

it occur, where affected, old vs new

injury

Mechanism of injury

(MOI)*

Past medical / surgical

history

Any medications

Chronic illnesses

Smoker / drinker

SAMPLE History*

IF IT SOUNDS

IMPORTANT, PUT

IT IN THE

HISTORY!

Mechanism of Injury The circumstance by which injury occurs

Assesses severity of injury

Affects the management of patient

Examples:

Gun shot to the thigh from 50 yards

Head-on collision during rugby

Fall onto head from 3 feet

Twisting of ankle during 100m race

Cramp in the pool during exercise

Blunt trauma to the stomach by cricket bat

High speed motor vehicular accident

History Taking

STEPS:

1. Scene size-up and BSI

2. Introduction to the patient and social history

3. Initial assessment (general inspection, assess ABCs,

alertness and mental status of patient AVPU, presenting

complaint)

4. Vital signs

5. SAMPLE History

6. Further considerations: GCS, OPQRST, DCAP-

BTLS

N.B. – When in doubt, ask a senior! Never

assume!

Approaching the Patient

Approaching the Patient - Considerations

Scene Size-Up and BSI

Scene size-up

Steps taken by the responding crew when approaching the

scene of an emergency call

Method of observation

Scene safety

BSI (Body Substance Isolation)

Any precaution taken by responder to protect his or herself

from coming into contact with patient’s bodily fluids or

other hazardous materials

Body Substance Isolation

Body Substance Isolation

Always clean hands after managing patients

Beginning and Approach

Considerations

Approach patient from

line of sight

Speak clearly

Introduce yourself

Be polite

Be professional (patient;

NOT date)

Reassure patient

Do not lie about extent of

injury

Get patient’s consent to

treat! (touching a patient

without approval is

battery)

BE CALM!

Social History

Considerations

Name

Age

Address

Contact number

Smoker: cigarettes, marijuana,

frequency of use

Drinking: socially, emotionally,

alone, quantity / quality /

frequency of drinking

Other illicit drug use

Any chronic illnesses,

personally or within family:

obesity, diabetes, high blood

pressure, sickle cell, bleeding

disorders, asthma, epilepsy,

fainting spells, migraines,

mental illness, high

cholesterol, valvular heart

disease, chronic infection

ABC…

A – Airway

Is nose / oral cavity clear of obstruction

B – Breathing

Respirations (breaths) per minute

One (1) respiration = 1 full inspiration (inhalation) + 1

full expiration (exhalation)

Breaths felt against side of face

Watch rise and fall of chest: shallow or deep, equal

or uneven on both sides

ABC… (cont’d)

C – Circulation

Pulse rate (“heart rate”)

Perfusion to brain

Check at wrists (radial), neck (carotid), ankle

(posterior tibial), top of foot (dorsalis pedis)

Never use thumb for assessment! (thumb contains

own pulse)

AVPU

Memory aid for classifying a patient’s level of

responsiveness or mental status

A – alertness

Patient may be awake but confused (orientation to

person, place, time, event)

V – verbal response

Response to normal speech/questions/commands vs

shouting to gain attention

AVPU (cont’d)

P – painful response

Patient only responsive to painful stimulus (Eg.

Pinched toe, sternal rub, supraorbital pressure)

U – unresponsive

Patient does not respond to any stimulus, whether it

be verbal or painful

Vital Signs

Outward signs of what is going on inside the body

Importance - gives responder an idea of state of

the patient, how best to manage and if to

transport to hospital

Vital Signs (cont’d)

Includes:

Respiration rate (breathing rate; oxygen saturation –

“O2 sat.”)

Pulse rate (“heart rate”)

Skin colour and state of mucous membranes (pink

membrane under eyelids, gums)

Temperature (measured under armpit, not orally)

Blood pressure (manual > digital)

SAMPLE

S – signs and symptoms

A – allergies

M – medications

P – pertinent past medical history

L – last oral intake

E – events leading to the injury or illness

S. Signs and Symptoms

Sign

Indication of a patient’s condition that is objective

I.e. – that which is observable and reported by the

medical authority

Can usually be tested by medial authority

E.g. – vital signs, vomitus, bleeding

Symptom

Indication of a patient’s health that is subjective

I.e. – that which is felt or reported by the patient but

cannot be observed by medical authority

E.g. – chest pains, dizziness, nausea

S. Signs and Symptoms (cont’d)

Considerations

How do you feel?

Do you feel better / worse?

Does anything help / aggravate the problem?

A. Allergies

Medication

Food

Environment (grass, pollen, dust)

Animals (fur, hair, bee/ wasp/ centipede/ ants/ spider/

scorpion stings and bites, faecal matter)

Anaphylaxis – life threatening!

Considerations

Is the patient wearing a medical ID badge?

What happens when you are exposed to stimulus?

Have you ever been hospitalized for this?

M. Medication

Medication

any substance which can be used for the diagnosis,

treatment, cure or prevention of disease

Drug

any substance that has a physiological effect when

ingested or otherwise introduced into the body

For the consideration of EMS, the term ‘drug’ can be used

interchangeably with ‘medication’ when questioning the

patient as one needs to know if the patient is using any

recreational drugs (e.g. – marijuana)

M. Medication (cont’d)

Considerations

Are you currently on any drugs: prescription, over-

the-counter, recreational?

What are you using the drugs for?

How often to you use these drugs and how much do

you use at a time?

Do you take any herbal supplements?

Are you allergic to any drugs?

Has your doctor recently switched your medication

or increased the dosage?

P. Pertinent Past History

Helps assess if this is a reoccurring or recent complaint

Considerations

Have you ever experienced this injury / illness before?

What did you do to make it better?

Did you seek medical consultation?

Have you been going to follow-ups for your complaint?

Have you had any recent hospitalizations / surgeries?

L. Last Oral Intake

Especially important for patients who present with fainting, dizziness or dehydration

Also important to note for patients requiring surgery since stomach contents can be vomited while under anaesthesia

Low blood sugar (hypoglycaemia)

Considerations

When last did you eat or drink?

What did you have to eat or drink?

E.g - a litre of liquids could constitute either 1 litre of juice or 1 litre of beer; not the same thing!

E. Events leading up to injury/illness

Considerations

When did the illness / injury occur?

What happened? How did it occur? What led up to it?

How long were you ill for?

Did you lose consciousness at point of impact /

injury?

Did you hit your head?

Further…

In some cases, one may need to use more specific

methods of assessment for a patient

Includes more advanced investigative techniques. If in

doubt, ALWAYS consult the senior responder! NEVER

ASSUME!

GCS (Glasgow Coma Scale)

Forms a more in-depth assessment of APVU

More qualitative scale of alertness and

consciousness

Further… (cont’d)

DCAP- BTLS

Mnemonic for assessment of specific soft tissue and

orthopaedic injury post trauma

Deformities, Contusions, Abrasions,

Puncture/Penetrations, Burns, Tenderness, Lacerations,

Swelling

OPQRST

mnemonic used for gauging patient’s current complaint of

pain

Onset, Palliation/Provocation, Quality, Radiation,

Severity, Time

Summary

What do you remember??

Review

1. When health care providers force their cultural values

onto their patients because they believe their values are

better, they are displaying __________.

A. ethnocentrism

B. proxemics

C. nonverbal communication

D. cultural imposition

Review (cont’d)

Answer: D

Rationale: Forcing your own cultural values onto others because you believe your

values are better is referred to as cultural imposition.

Review (cont’d)

2. Which of the following statements about the patient care

report (PCR) is true?

A. It is not a legal document in the eyes of the law.

B. It cannot be used for patient billing information.

C. It helps ensure efficient continuity of patient care.

D. It is for use only by the prehospital care provider.

Review (cont’d)

Answer: C

Rationale: The PCR is an important document for more than one reason. It helps

to ensure efficient continuity of patient care by providing the hospital with an

account of all prehospital assessments and treatment. It also serves as a legal

document that reflects the care provided by the EMT.

Review (cont’d)

3. After receiving an order from medical control over the

radio, the EMT should:

A. carry out the order immediately.

B. disregard the order if it is not understood.

C. obtain the necessary consent from the patient.

D. repeat the order to the physician word for word.

Review (cont’d)

Answer: D

Rationale: After receiving an order from medical control, the EMT should repeat

the order back to the physician word for word. This will ensure that he or she

heard the order correctly. After confirming the order, the EMT should obtain the

necessary consent from the patient.

Review (cont’d)

4. A 60-year-old man complains of chest pain. He is conscious and alert and

denies shortness of breath. Which of the following questions would be the

MOST appropriate to ask him?

A. “Were you exerting yourself when the chest pain began?”

B. “Does the pain in your chest move to either of your arms?”

C. “Does the pain in your chest feel like a stabbing sensation?”

D. “Do you have any heart problems or take any medications?”

Review (cont’d)

Answer: D

Review (cont’d)

5. During your assessment of a 20-year-old man with a severe headache and

nausea, you ask him when his headache began, but he does not answer your

question immediately. You should:

A. repeat your question because he probably did not hear you.

B. allow him time to think about the question and respond to it.

C. ask him if he frequently experiences severe headaches and nausea.

D. tell him that you cannot help him unless he answers your questions.

Review (cont’d)

Answer: B

Review (cont’d)

6. In what manner should you act and speak with a patient?

A. passive

B. authoritative

C. loud and official

D. calm and confident

Review (cont’d)

Answer: D

Review (cont’d)

7. When communicating with a visually impaired patient, you should:

A. determine the degree of the patient’s impairment.

B. expect him or her to have difficulty understanding.

C. recall that most visually impaired patients are blind.

D. possess an in-depth knowledge of sign language.

Review (cont’d)

Answer: A

Review (cont’d)

8. The patient care report (PCR) ensures:

A. research data.

B. legal protection.

C. quality assurance.

D. continuity of care.

Review (cont’d)

Answer: D

Review (cont’d)

9. All information recorded on the PCR must be:

A. typewritten or printed.

B. considered confidential.

C. a matter of public record.

D. reflective of your opinion.

Review (cont’d)

Answer: B

Reference

Brady – Emergency Care; Daniel Limmer, Michael F. O’Keefe (11th Ed.)

Jones and Bartlett – Emergency Care and Transportation of the Sick and

Injured – Andrew N. Pollak, et al (10th Ed.)