Communication and Documentation

Radio systems

An EMS radio system is built from a handful of components, each with a different job and a different reach. The table below describes each one.

Table 17.1Radio systems

Principles of radio communication

Good radio communication starts before you key the microphone. Make sure the radio is on and the volume set, reduce the background noise around you, and listen to confirm the frequency is clear before you transmit. Press the push-to-talk (PTT) button and wait 1 second before speaking, so the first word is not cut off, and hold the microphone 2 to 3 inches from your lips.

Identify the unit you are calling first, then yourself, and wait for the "stand by" clearance before continuing. Speak slowly and clearly, and keep each transmission to 30 seconds or less. Use plain English rather than codes. When a number could be misheard, say the number and then its individual digits, as in "fifteen, one-five."

Because radio traffic can be overheard, never give a patient's name over the air, and never use profanity or slander. Keep your language objective and impartial. By convention you say "we" rather than "I," and "affirmative" and "negative" rather than "yes" and "no." Report your assessment findings, not a field diagnosis: the patient "complains of abdominal pain," not "probably has appendicitis."

Radio medical report — 12 parts

The radio medical report tells the receiving hospital what is coming so that it can decide where in the emergency department (ED) the patient belongs and have the right staff ready before you arrive. It has 12 parts, given in this order:

1. Unit identification and provider level
2. Estimated time of arrival (ETA)
3. Patient age and sex
4. Chief complaint
5. Brief pertinent history of the present illness (HPI)
6. Major past illnesses
7. Mental status
8. Baseline vital signs
9. Pertinent physical exam findings
10. Emergency care given
11. Response to care
12. Contact with medical direction, if it is needed or you have questions

Deliver the report in a steady tone even when the patient is critical. A calm, ordered report is easier to act on than an urgent one.

Medical direction communication rules

When you speak with medical direction, the physician's orders are based entirely on what you report, so speak slowly and clearly. After you receive an order, repeat it back word for word, and do the same when a request is denied. If an order is unclear, ask the physician to repeat it, and then repeat it back once you understand it.

If an order seems inappropriate, question it. Questioning may reveal that the physician misunderstood something you reported, or it may bring out an explanation that makes the order clear.

Therapeutic communication

Communication with the patient is part of care, not a preliminary to it. Make eye contact, while respecting the cultural norms of patients for whom direct eye contact is considered rude, and position yourself at or below the patient's eye level. Your posture sends a message of its own: an open stance conveys warmth, and a closed stance conveys authority.

Use plain language, and explain each procedure before you perform it. Be honest, even about pain. Address the patient by their proper name and title until they tell you otherwise. Above all, listen. Do not re-ask questions the patient has already answered, and write the answers down.

Some patients need an adjusted approach. For a patient who is hard of hearing, speak slowly and make sure they can see your mouth. For a patient who is blind or visually impaired, speak at a normal volume and describe what you are doing as you do it. When there is a language barrier, use an interpreter or a translation service. With children, come down to their level, be truthful, and involve the parents.

Prehospital Care Report (PCR) — 5 functions

The prehospital care report (PCR) is the written record of the call, and it serves five functions:

1. It is the patient care record, and it becomes part of the permanent hospital record.
2. It is a legal document that may be subpoenaed.
3. It supplies administrative data for billing and insurance.
4. It supports education and research, including trend analysis, resource deployment and the identification of training needs.
5. It is the basis of quality improvement (QI/QA/CQI), in which reports are reviewed for conformity with the standard of care.

Complete the PCR as soon as possible, ideally before you leave the hospital, because the report is most accurate while your memory is fresh. When the full PCR cannot be completed before you leave, an abbreviated version called a drop report or transfer report is left at the hospital.

Narrative writing rules

The narrative distinguishes objective from subjective information. Objective findings are observable and measurable, such as "BP 110/80." Subjective information is a symptom the patient reports, written in quotation marks, or your own impression. Avoid opinions that go beyond your scope. Anything you did not observe yourself goes in quotation marks with its source, as in "Bystander stated 'patient passed out before crashing.'" If the patient is conscious and oriented, record the chief complaint in the patient's own words, quoted.

Document pertinent negatives, the findings you explored and found absent, such as "denies pain in right arm." A pertinent negative shows that you checked. Do not use radio codes or nonstandard abbreviations; write legibly, spell correctly and use correct medical terminology.

The rule that governs all documentation is this: "If it's not written down, you didn't do it." The same rule applies in reverse to treatment. Treat and document on the basis of the mechanism of injury (MOI) or the patient's condition, even when the patient has no pain and no complaint.

Legal & special documentation issues

The PCR is protected under the Health Insurance Portability and Accountability Act (HIPAA). Keep it in locked storage and distribute it only as HIPAA and state and local rules allow.

A patient refusal is the documentation situation most likely to be examined later. Document your attempts to persuade the patient, assess the patient's capacity to refuse, and inform the patient of the consequences of refusing. If the patient allows it, perform a secondary assessment and take vital signs anyway. Have the patient sign a refusal form; if the patient will not sign, document the refusal to sign and have witnesses. Suggest alternative care, and make sure a responsible person stays with the patient.

Never document care you did not give or findings you did not observe. An error of omission is a step that was left out; document only what was actually done. An error of commission is a wrong action that was performed; document what happened, the correction you made, and your notification of medical direction and the hospital.

Correcting an error depends on where the report is. On a paper report that is still intact and has not been copied, draw a single line through the error, initial it and write the correction beside it. Never obliterate the original. On a paper report that has already been submitted, draw a single line through the error, add your initials and the date, and add the correction as a separate note.

At a multiple-casualty incident (MCI), triage tags track the chief complaint, injuries, vital signs and treatment as patients move between areas, and the tags are later used to complete a standard PCR. A PCR from an MCI will not have the normal level of detail, and that is acceptable given the circumstances.