NREMT EMT 4: Patient Treatment and Transport - Communication and Documentation, Radio Reports, Patient Handoff, Prehospital Care Report, PCR/ePCR, Legal, Quality Assurance, QA

What This Is: Communication and Documentation

Effective communication and documentation are crucial in emergency medical services (EMS). When an ambulance arrives at a scene, the EMTs need to quickly and accurately report the situation to the hospital and other emergency responders. This ensures that the patient receives the right care at the right time. Think of it like ordering food at a restaurant – you need to give the waiter clear instructions so they can bring you the right dish.

Key Steps / Core Facts

• Radio Report: A clear, concise summary of the patient's condition and situation. Matters because it helps the hospital prepare for the patient's arrival. Example: "Patient is a 35-year-old male with chest pain, shortness of breath, and a history of heart disease." (Use the SAMPLE mnemonic: Size, Activity, Mechanism, Allergies, Past medical history, Last oral intake)
• Patient Handoff: A smooth transfer of patient care from one EMT to another. Matters because it prevents errors and ensures continuity of care. Example: "Handing off a patient to a new EMT, say 'Patient's name, age, and condition, and any notable findings.'"
• Prehospital Care Report (PCR/ePCR): A detailed document of the patient's care and treatment. Matters because it helps the hospital and other emergency responders understand the patient's condition and treatment. Example: "A PCR should include the patient's vital signs, medications administered, and any notable events during transport."
• Legal Quality Assurance (QA): Ensuring that patient care meets established standards and guidelines. Matters because it protects patients, EMTs, and the EMS system from liability. Example: "QA involves reviewing patient care records to ensure that EMTs followed established protocols and guidelines."
• Chain of Command: A clear line of communication between EMTs, dispatchers, and hospital staff. Matters because it ensures that patient care is coordinated and effective. Example: "The chain of command starts with the dispatcher, who communicates with the EMTs, who then communicate with the hospital."
• Vital Signs: Measurements of the patient's vital functions, such as heart rate, blood pressure, and respiratory rate. Matters because they help EMTs assess the patient's condition and make informed decisions. Example: "Normal blood pressure is between 90/60 and 120/80 mmHg." (Use the AVPU mnemonic: Alert, Verbal, Pain, Unresponsive)
• Medication Administration: The safe and effective use of medications in the field. Matters because it can be life-saving or even deadly if not done correctly. Example: "Always check the patient's medical history before administering medications." (Use the OPQRSTI mnemonic: Onset, Provocation, Quality, Region, Severity, Time, Investigate)
• Documentation: Accurate and complete recording of patient care and treatment. Matters because it helps EMTs and hospital staff understand the patient's condition and treatment. Example: "Document all patient interactions, including conversations and observations."
• Communication with Patients: Clear and respectful communication with patients and their families. Matters because it helps build trust and ensures that patients understand their care and treatment. Example: "Always introduce yourself and explain the patient's condition in simple terms."
• Communication with Other Responders: Clear and concise communication with other emergency responders, such as police and fire departments. Matters because it helps ensure a coordinated response and effective patient care. Example: "Use clear and concise language when communicating with other responders, and always identify yourself and your role."

What Laypeople Can Do

• If someone collapses, first check for danger (oncoming traffic, fire). Then shout and tap their shoulder.
• If someone is having a seizure, turn them onto their side and clear the area around them.
• If someone is experiencing chest pain, call 911 and stay with them until help arrives.
• If someone is having trouble breathing, help them sit up and stay with them until help arrives.
• If someone is experiencing a medical emergency, stay calm and follow the instructions of the emergency responders.

Common Mistakes

• Mistake: Not documenting patient care and treatment accurately and completely.
• Fix: Always document patient interactions, including conversations and observations, and ensure that the documentation is accurate and complete.
• Mistake: Not communicating clearly and respectfully with patients and their families.
• Fix: Always introduce yourself and explain the patient's condition in simple terms, and be respectful and empathetic in your communication.
• Mistake: Not following established protocols and guidelines for patient care and treatment.
• Fix: Always follow established protocols and guidelines, and seek guidance from experienced EMTs or medical professionals if you are unsure.

Quick Practice Scenarios

1. A patient is experiencing chest pain and shortness of breath. What should you do first?

Answer: Call 911 and stay with the patient until help arrives.

1. A patient is having a seizure. What should you do first?

Answer: Turn them onto their side and clear the area around them.

1. A patient is experiencing a medical emergency and is unresponsive. What should you do first?

Answer: Start CPR and call 911.

Last-Minute Exam Cram

• Normal blood pressure is between 90/60 and 120/80 mmHg.
• Agonal breathing is NOT normal breathing – start CPR.
• The SAMPLE mnemonic is used for radio reports: Size, Activity, Mechanism, Allergies, Past medical history, Last oral intake.
• The AVPU mnemonic is used for assessing patients: Alert, Verbal, Pain, Unresponsive.
• Always check the patient's medical history before administering medications.
• The OPQRSTI mnemonic is used for assessing patients: Onset, Provocation, Quality, Region, Severity, Time, Investigate.
• A PCR should include the patient's vital signs, medications administered, and any notable events during transport.
• Always document patient interactions, including conversations and observations.
• The chain of command starts with the dispatcher, who communicates with the EMTs, who then communicate with the hospital.