1. National Ski Patrol, Outdoor Emergency Care, 5 th Ed. ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Chapter 8 Medical Communications and Documentation

2. National Ski Patrol, Outdoor Emergency Care, 5 th Ed. ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Objectives 8.1 List the two types of medical communications. 8.2 List the essential content that should be included in all verbal communications, using the acronym SAILER. 8.3 List the components for the following methods used to complete a PCR: a.SOAP b.CHEATED continued

3. National Ski Patrol, Outdoor Emergency Care, 5 th Ed. ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Objectives 8.4 List the characteristics of good report writing using the acronym FACTUAL- OEC. 8.5 Describe and demonstrate how to correct an error on a written report. 8.6 List two criteria that must be documented on a patient refusal. 8.7 List four injuries or crimes that a mandated reporter must report to authorities. continued

4. National Ski Patrol, Outdoor Emergency Care, 5 th Ed. ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Objectives 8.8 Demonstrate how to complete a sample patient care report with 100-percent accuracy. 8.9 Demonstrate how to provide an oral report.

5. National Ski Patrol, Outdoor Emergency Care, 5 th Ed. ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Topics Communications Basics Verbal and Written Communications Notes / Reports / Forms Characteristics of Good Report Writing Essential Content of Medical Communications Special Circumstances

6. National Ski Patrol, Outdoor Emergency Care, 5 th Ed. ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Case Presentation Your patient, found at the base of a large rock, complains of neck and back pain. Your assessment also reveals the loss of movement and sensation below the waist. Patient and witness information is recorded. The patient is packaged and evacuated to the first aid area.

7. National Ski Patrol, Outdoor Emergency Care, 5 th Ed. ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Communications Basics Communication is a process in which a message is transmitted from a sender to a receiver. It is vital that the sender and receiver have the same message. ◦ Restatement can help ensure that the correct information has been received Medical communication is the transfer of health care related information.

8. National Ski Patrol, Outdoor Emergency Care, 5 th Ed. ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Verbal Communications Transfers information through spoken words, and may be face to face or device related With patient / witnesses at the scene With the first aid area via radio With patrol help when it arrives With personnel at the first aid area ◦ Hand-off report continued

9. National Ski Patrol, Outdoor Emergency Care, 5 th Ed. ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Verbal Communications Non-verbal elements may affect the message Present essential information that is clear, concise, and organized SAILER acronym may be used to radio patient information and request assistance Sender verifies receiver’s accuracy

10. National Ski Patrol, Outdoor Emergency Care, 5 th Ed. ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY SAILER Sex of patient Age of patient Incident – chief complaint Location of the accident/patient Equipment needed Resources needed

11. National Ski Patrol, Outdoor Emergency Care, 5 th Ed. ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Written Communications Documents the patient encounter and becomes a permanent record May include informal notes as well as formal documents ◦ Field care notes ◦ Incident report forms ◦ Patient care reports continued

12. National Ski Patrol, Outdoor Emergency Care, 5 th Ed. ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Written Communications Accurately describe facts associated with the accident continued

13. National Ski Patrol, Outdoor Emergency Care, 5 th Ed. ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Written Communications Copyright Edward McNamara

14. National Ski Patrol, Outdoor Emergency Care, 5 th Ed. ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Field Care notes Taken during the rescue operation Essential current information May become part of other reports ◦ Hand off report ◦ Formal accident report

15. National Ski Patrol, Outdoor Emergency Care, 5 th Ed. ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Accident Report Forms May be from NSAA, Insurance Co., Area – paper or computer generated Record fundamental information ◦ Patient identification ◦ Cause of injury ◦ Who was at the accident scene ◦ Care given at the scene ◦ Care given in the aid room ◦ Further comments Report corrections or additions

16. National Ski Patrol, Outdoor Emergency Care, 5 th Ed. ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Patient Care Reports Used to record specific info about medical care provided to the patient ◦ “If it isn’t documented, it didn’t happen" May be open, closed, or mixed in format Use SOAP / CHEATED Complete reports are part of risk management continued

17. National Ski Patrol, Outdoor Emergency Care, 5 th Ed. ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Patient Care Reports continued

18. National Ski Patrol, Outdoor Emergency Care, 5 th Ed. ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Patient Care Reports

19. National Ski Patrol, Outdoor Emergency Care, 5 th Ed. ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY SOAP & CHEATED Subjective Objective Assessment Plan Chief complaint History Examination Assessment Treatment Evaluation Disposition

20. National Ski Patrol, Outdoor Emergency Care, 5 th Ed. ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Characteristics of Good Report Writing Facts Accurate Complete Terms are Unbiased Avoid slang Legible Organized Error Free Checked

21. National Ski Patrol, Outdoor Emergency Care, 5 th Ed. ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Case Update Using your notes, you give an OEC Technician or the senior medical person on duty in the aid room or clinic an oral report about the patient. This report includes a complete description of your initial impressions of the patient, the nature of the patient’s injury, the patient’s level of responsiveness, results from the primary and secondary assessments, and the basic care you provided.

22. National Ski Patrol, Outdoor Emergency Care, 5 th Ed. ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Essential Content of Medical Communications Age and Gender Chief complaint History of present illness Past medical history Physical exam Impression Treatment Response to treatment

23. National Ski Patrol, Outdoor Emergency Care, 5 th Ed. ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Special Circumstances Refusal of care Incidents that must be reported to authorities Accident investigations

24. National Ski Patrol, Outdoor Emergency Care, 5 th Ed. ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Case Disposition You write a PCR to document the case using the SOAP format. You give the ambulance crew an oral hand-off report and a copy of your patient care report. You complete an incident report form and place both documents into the patrol record box. The patient was admitted to the hospital with a spinal fracture. The medical director identified the case as an excellent example of good documentation.

25. National Ski Patrol, Outdoor Emergency Care, 5 th Ed. ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Chapter Summary Effective medical communications is one of the hallmarks of a highly skilled OEC Technician. Careful documentation is important both for medical and legal reasons. Medical communications include oral communication and written documentation. continued

26. National Ski Patrol, Outdoor Emergency Care, 5 th Ed. ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Chapter Summary Breakdowns in the communication process can create misunderstandings and errors. An oral hand-off report should take less than 60 seconds to complete. Patients who refuse medical assistance must have the capacity to do so. continued

27. National Ski Patrol, Outdoor Emergency Care, 5 th Ed. ©2012 by Pearson Education, Inc., Upper Saddle River, NJ BRADY Chapter Summary Thoroughly document all patient refusals. If it isn’t documented, it didn’t happen; document reports completely and accurately. Write good reports by being a FACTUAL OEC Technician.