Chapter 8
Medical
Communications
and Documentation
BRADY
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
BRADY
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
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.
b.
BRADY
SOAP
CHEATED
continued
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
Objectives
8.4 List the characteristics of good report
writing using the acronym FACTUALOEC.
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
continued
authorities.
BRADY
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
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.
BRADY
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
Topics
 Communications
Basics
 Verbal and Written Communications
 Notes / Reports / Forms
 Characteristics of Good Report
Writing
 Essential Content of Medical
Communications
 Special Circumstances
BRADY
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
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.
BRADY
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
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
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continued
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
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
BRADY
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
SAILER
 Sex
of patient
 Age of patient
 Incident – chief complaint
 Location of the accident/patient
 Equipment needed
 Resources needed
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National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
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
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National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
Written Communications
 Accurately
describe facts associated
with the accident
continued
BRADY
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
Written Communications
Copyright Edward McNamara
BRADY
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
Field Care notes
 Taken
during the rescue operation
 Essential current information
 May become part of other reports
◦ Hand off report
◦ Formal accident report
BRADY
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
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
BRADY
corrections or additions
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
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
BRADY
continued
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
Patient Care Reports
continued
BRADY
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
Patient Care Reports
BRADY
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
SOAP & CHEATED
 Subjective
 Objective
 Assessment
 Plan
BRADY
 Chief
complaint
 History
 Examination
 Assessment
 Treatment
 Evaluation
 Disposition
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
Characteristics of Good
Report Writing
Facts
 Accurate
 Complete
 Terms are
 Unbiased
 Avoid slang
 Legible
 Organized
 Error Free
 Checked

BRADY
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
Essential Content of Medical
Communications
 Age
and Gender
 Chief complaint
 History of present illness
 Past medical history
 Physical exam
 Impression
 Treatment
 Response to treatment
BRADY
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
Special Circumstances
 Refusal
of care
 Incidents that must be reported to
authorities
 Accident investigations
BRADY
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
BRADY
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
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
BRADY
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
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
BRADY
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
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.
BRADY
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
BRADY
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
BRADY
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
BRADY
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
BRADY
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
BRADY
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
BRADY
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
 THE
END
 http://www.youtube.com/watch?v=Gi
UNsDVjCbo
BRADY
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ