EMT-Basic Exam: The Basics of Patient Assessment - Documentation and Communication

The EMT-Basic exam will include questions about communicating with patients, bystanders, fellow emergency personnel, and dispatch. You will also encounter questions about written communication, known as documentation. These are two important processes that many experienced EMT-Basics perform with little to no hesitation every day. On the scene of an emergency, EMT-Basics have to communicate effectively and clearly and their notes should be legible and accurate.

1. Procedures for Radio Communication
When you radio dispatch, state the location of your unit, that you have received and understood the call, and that you are responding to the call. Depending on the area, you may need to let other agencies and units know that you are responding to the call. When you arrive on the scene, you need to alert the dispatcher. Contact the dispatcher once again when you reach the patient. You must also notify the dispatcher when you leave the scene with the patient, when you arrive at the hospital, when you leave the hospital, and when you arrive at your station. The dispatcher will record these times and they will be available for you if you need to refer to them when writing your report.
You will also use the radio when communicating with the medical direction physician. Once you have completed your initial assessment of the patient and you have determined that the patient needs immediate medical care, you should radio the medical direction physician with the following information:
- Patient’s gender and age
- Patient’s chief complaint
- Patient’s past medical history
- Patient’s mental status
- Your assessment findings and vital signs
- Any emergency care already provided
- Estimated time you’ll begin transport
- Estimated time of arrival at the hospital
The medical direction physician will use this information to tell you what you need to do to help your patient. As the physician gives you directions, repeat them to be sure that you understood the instructions completely. Once the task is complete, ask the medical direction physician if he or she can inform the medical facility of your patient’s condition. If the physician cannot do this, you will have to update the hospital yourself.

Tip: After pressing the push-to-talk button on your radio, wait a moment before speaking. When you do speak into the radio, hold the microphone approximately 5 to 7 centimeters away from your mouth. This will ensure that your message is transmitted clearly.

2. Minimum Data Sets
Every EMT-Basic is required to obtain two sets of information when responding to a call: patient information and administrative information, as detailed in the table below. Combined, EMT-Basics use these sets to write a prehospital care report. All the data in these sets must be accurate, especially the recorded times. Remember to record times using the 24-hour system.

3. Prehospital Care Report
Because a prehospital care report is a legal document, it is considered confidential; therefore, you should never share information you read or report with anyone else. This report provides information about the patient’s status when EMS arrived on the scene, the care that the EMT-Basics provided, and any changes in the patient’s condition as he or she was transported to a medical facility. All statements in a prehospital care report should be objective. The patient’s nurses, doctors, surgeons, and insurance company agents read the prehospital care report to determine the type of care that a patient needs. Even researchers and medical students may benefit from an accurate and legible prehospital care report. The prehospital care report can also be shared with anyone involved in the patient’s ongoing care.

4. Documentation of Patient Refusal
If a patient is competent and is not under the influence of drugs or alcohol, he or she has the right to refuse treatment and transport. Patients who are under the influence of drugs or alcohol are not considered competent, and, therefore, cannot refuse care. EMT-Basics can consult their medical direction physician if they have questions about the patient’s competence. Before leaving the scene, try to convince the patient to go to the hospital and inform the patient of the risks of refusing treatment. Offer alternatives to transporting the patient in the ambulance. For example, the patient can ride with a family member in the family’s car and the ambulance can follow. If the patient still refuses, call the medical direction physician and ask him or her to speak with the patient. Next, have the patient sign a patient refusal form. Ask a member of your unit to sign the form as a witness. Explain that you will return if the patient changes his or her mind.

Tip: A medical direction physician can help you determine a patient’s competency.

Related Topics You Should Review:
- General radio communications principles
- Communication systems, components, and maintenance
- Trending
- Traditional versus nontraditional prehospital care reports
- Common medical abbreviations
- Correction of documentation errors
- Documentation of special situations including multiple casualty incidents