CHAPTER 4 ASSESSMENT IN ACTION Emergency Care and Transportation of the Sick and Injured, Twelfth Edition AAOS Communication and Documentation You are dispatched at 0130 hours to an apartment complex for a gunshot wound. While you are en route, dispatch informs you that law enforcement has arrived and secured the scene. Upon arrival, you observe a law enforcement officer kneeling next to a teenager while two other officers interview witnesses. The patient is a 17-year-old boy with a single gunshot wound to the left upper leg. He is screaming in pain and states, “I can’t believe he did this to me! I didn’t know she was his sister!” You locate the wound and control the bleeding with direct pressure. Assessment of his vital signs shows a pulse rate of 96 beats/min; a respiratory rate of 22 breaths/min; blood pressure of 104/76 mm Hg; an Spo2 of 98% on room air; and his skin is pink, warm, and dry. 1. Encouraging this patient to provide more information about his injury is an example of which therapeutic communication technique? A. Facilitation B. Clarification C. Reflection D. Interpretation 2. Which of the following actions should you avoid while interviewing this patient? A. Being empathetic B. Asking leading or biased questions C. Clarifying information D. Giving the patient time to answer the question 3. If this patient refuses to be transported to the hospital, you should: A. contact medical control. B. ask law enforcement to take him into custody. C. immediately stop patient care and leave. D. find another person to continue medical care. 4. As you radio the hospital to give a report on your patient, remember to: A. provide as much detail as possible. B. use code words to protect the patient’s identity. C. speak as quickly and loudly as possible. D. mention that this is an “alert” level patient as soon as possible. 5. What information should you include in your initial report to the hospital? A. Your estimated time of arrival B. The patient’s full name and date of birth C. The address of the location you are coming from D. Your personal opinion of the patient’s condition 6. As you write your narrative for this call, it is important to include: A. your opinions. B. many abbreviations. C. physical assessment findings. D. the address of your location. Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com. Emergency Care and Transportation of the Sick and Injured, Twelfth Edition AAOS 7. After you submit the electronic PCR for this call, you realize that you accidentally docu­mented the wrong vital signs. You should: A. leave the record as it is and seek legal advice. B. notify your agency’s information technology department. C. follow your agency’s directions for making an amendment. D. say nothing and hope that the error goes unnoticed. 8. Your partner takes several photos of the patient and the scene to post online to share with friends. This could be a violation of: A. Internet laws. B. patient care report protocol. C. NEMSIS. D. HIPAA. 9. When communicating in a crisis it is vital to: A. establish your authority as an emergency responder. B. consider the perspective of the other person. C. call for additional resources. D. immediately exert your influence to move the situation forward. 10. To establish a mental model, it is vital to answer which of the following questions? A. What got us to this point in care? B. What are the future possible options? C. What category does this patient fit into? D. How often does this situation occur? Answers to Assessment in Action Questions 1. Answer: A Facilitation 2. Answer: B Asking leading or biased questions 3. Answer: A contact medical control. 4. Answer: D remain objective and impartial. 5. Answer: A Your estimated time of arrival 6. Answer: C physical assessment findings. 7. Answer: C follow your agency’s directions for making an amendment. 8. Answer: D HIPAA 9. Answer: B consider the perspective of the other person. 10. Answer: A What got us to this point in care? Copyright © 2021 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com.
