Communication, Documentation, History Taking
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This document discusses communication and documentation in EMS, including history taking. It covers the importance of verbal and non-verbal communication skills for gathering information and coordinating care. Documentation in the form of a patient care report is described as the patient's permanent medical record that demonstrates appropriate care and aids future treatment. Taking a thorough history that includes signs and symptoms, allergies, medications, past medical history, last oral intake, and events leading to the injury or illness is also discussed.
Communication, Documentation, History Taking
- 1. Communication, Documentation, History Taking Prepared by Odane P. Hamilton, EMT Sept. 2015
- 2. 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
- 3. 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
- 4. Communication Uses various communication techniques and strategies: Both verbal and nonverbal Encourages patients to express how they feel Achieves a positive relationship with patient
- 5. 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
- 8. 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.
- 9. 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
- 10. 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
- 11. 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
- 12. 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?”
- 13. 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?”
- 14. Communication Communication Tools There are many powerful communication tools that EMRs can use: Facilitation Silence Reflection Empathy Clarification Confrontation Interpretation Explanation Summary
- 15. 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.
- 16. 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.
- 17. 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.
- 18. 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.
- 19. 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.
- 20. 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
- 21. Documentation Patient care report (PCR) Also known as prehospital care report Legal document Records all care from dispatch to hospital arrival
- 22. Documentation The PCR serves six main functions: Continuity of care Legal documentation Education Administrative information Essential research record Evaluation and continuous quality improvement
- 23. 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
- 24. WHAT IS A PATIENT’S HISTORY? WHY ARE PATIENT HISTORIES IMPORTANT?
- 25. 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*
- 26. IF IT SOUNDS IMPORTANT, PUT IT IN THE HISTORY!
- 27. 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
- 28. 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)
- 29. 4. Vital signs 5. SAMPLE History 6. Further considerations: GCS, OPQRST, DCAP- BTLS N.B. – When in doubt, ask a senior! Never assume!
- 31. Approaching the Patient - Considerations
- 32. 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
- 34. Body Substance Isolation Always clean hands after managing patients
- 35. 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!
- 36. 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
- 37. 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
- 38. 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)
- 39. 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
- 40. 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
- 41. 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
- 42. 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)
- 43. 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
- 44. 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
- 45. S. Signs and Symptoms (cont’d) Considerations How do you feel? Do you feel better / worse? Does anything help / aggravate the problem?
- 46. 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?
- 47. 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)
- 48. 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?
- 49. 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?
- 50. 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!
- 51. 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?
- 52. 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
- 53. 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
- 54. Summary What do you remember??
- 55. 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
- 56. 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.
- 57. 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.
- 58. 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.
- 59. 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.
- 60. 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.
- 61. 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?”
- 63. 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.
- 65. 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
- 67. 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.
- 69. Review (cont’d) 8. The patient care report (PCR) ensures: A. research data. B. legal protection. C. quality assurance. D. continuity of care.
- 71. 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.
- 73. 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.)