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Referencing the content of EMT-Basic training and emergency patient care

EMT Basic · Chapter 4

Communications and Documentation

Why this chapter matters

Therapeutic communication improves assessment accuracy; the PCR is a medicolegal record and continuity tool.

Learning objectives (16)

  1. Demonstrate completion of a PCR — Knowledge/skills objective (printed page 118); confirm wording in your course copy.
  2. Demonstrate how to make a simulated, concise radio transmission with dispatch — Knowledge/skills objective (printed page 118); confirm wording in your course copy.
  3. Demonstrate the techniques of successful cross-cultural communication — Knowledge/skills objective (printed page 118); confirm wording in your course copy.
  4. Describe how to document refusal of care, including the legal implications — Knowledge/skills objective (printed page 118); confirm wording in your course copy.
  5. Describe the basic principles of the various types of communications equipment used in EMS — Knowledge/skills objective (printed page 118); confirm wording in your course copy.
  6. Describe the factors and strategies to consider for therapeutic communication with patients — Knowledge/skills objective (printed page 117); confirm wording in your course copy.
  7. Describe the use of radio communications, including the proper methods of initiating and terminating a radio call — Knowledge/skills objective (printed page 118); confirm wording in your course copy.
  8. Describe the use of written communications and documentation — Knowledge/skills objective (printed page 117); confirm wording in your course copy.
  9. Discuss special considerations in communicat- ing with older people, children, patients who are hard of hearing, visually impaired patients, and non–English-speaking patients — Knowledge/skills objective (printed page 117); confirm wording in your course copy.
  10. Discuss state and/or local special reporting requirements, such as for gunshot wounds, dog bites, and abuse — Knowledge/skills objective (printed page 118); confirm wording in your course copy.
  11. Discuss the techniques of effective verbal communication — Knowledge/skills objective (printed page 117); confirm wording in your course copy.
  12. Explain the legal implications of the PCR — Knowledge/skills objective (printed page 118); confirm wording in your course copy.
  13. Explain the skills that should be used to communicate with family members, bystanders, people from other agencies, and hospital personnel — Knowledge/skills objective (printed page 117); confirm wording in your course copy.
  14. List the correct radio procedures in the following phases of a typical call: initial receipt of call, en route to call, on scene, arrival at hospital (or point of transfer), and re — Knowledge/skills objective (printed page 118); confirm wording in your course copy.
  15. List the proper sequence of information to communicate in radio delivery of a patient report — Knowledge/skills objective (printed page 118); confirm wording in your course copy.
  16. State the purpose of a patient care report (PCR) and the information required to complete it — Knowledge/skills objective (printed page 117); confirm wording in your course copy.

Chapter outline

  1. Therapeutic communication: rapport, empathy, cultural humility; barriers (language, hearing, cognitive impairment, distress)
  2. Interview structure: chief complaint, OPQRST-style hooks where course introduces them, SAMPLE preview if used later
  3. Question types: open vs closed; avoiding leading questions in forensic-sensitive contexts
  4. Radio: concise structured reports; closed channels vs PHI risk on open air
  5. Written/ePCR documentation: objective vs subjective; times; treatments and responses; disposition
  6. Formats: narrative structures your agency teaches (e.g. CHART-style awareness; SaCHART/DRAT as labels when present in text)
  7. Medical necessity language for transport when billing/regulatory context applies at EMT awareness level
  8. Handoffs: SBAR-style discipline at hospital door
  9. Health information exchange awareness (HIE) without violating privacy
  10. Digital signatures and amend / late-entry policies (conceptual)

Vocabulary (16)

Closed-ended question
Question answered with yes/no or a single fact. Utilization: Use to clarify specifics after the patient tells their story.
Digital signature
Electronic attestation on ePCR. Utilization: Legal validity per agency system.
DRAT
Structured documentation framework emphasizing dispatch reason, response, assessment, transport. Utilization: Another structured narrative style referenced in modern EMS documentation teaching.
Handoff (SBAR / I-PASS style)
Structured transition communication to hospital teams. Utilization: Reduces missed allergies, interventions, and pending problems.
Health information exchange (HIE)
Electronic sharing of patient data among authorized providers. Utilization: May inform destination care; still verify identity and respect privacy limits.
Jargon
Insider terms that confuse patients or allied staff. Utilization: Translate for patient understanding.
Learning
Network-MLN/MLNProducts/Downloads
Medical necessity
Clinical justification that transport or care aligns with patient needs and payer rules. Utilization: Document findings that support level of service and destination decisions.
Minimum data set
Required chart elements for billing or reporting. Utilization: Completeness prevents downstream administrative failure.
Narrative
Free-text story of the call with assessment and response. Utilization: Must match times, vitals, and treatments recorded elsewhere.
Open-ended question
Question inviting narrative description (for example, what happened today). Utilization: Starts interviews and elicits the patient's concerns without leading.
PCR / ePCR
Patient care report: legal record of assessment, treatment, times, and disposition. Utilization: Complete promptly with objective findings, narrative, and signatures per policy.
Radio communication
Structured voice reports on assigned channels with concise essential data. Utilization: Follow agency format; repeat critical values; avoid PHI over open channels when inappropriate.
Reflective listening
Restating or summarizing the patient's words to confirm understanding. Utilization: Builds trust and reduces misunderstandings during emotional distress.
SaCHART
Structured narrative format (example mnemonic): subjective, chief complaint, history. Utilization: Helps organize charting when your agency adopts structured narrative models.
Therapeutic communication
Patient-centered dialogue that builds rapport and gathers accurate information. Utilization: Use open-ended prompts early, then focused questions; avoid interrupting and minimize jargon.

Sequence practice (2 puzzles on Quiz Me)

SAMPLE history

Order the components of the SAMPLE history mnemonic.

  1. S — Signs and symptoms
  2. A — Allergies
  3. M — Medications
  4. P — Pertinent past medical history
  5. L — Last oral intake
  6. E — Events leading up to the illness or injury
OPQRST pain assessment

Order the OPQRST questions for assessing pain or discomfort.

  1. O — Onset (what were you doing when it started?)
  2. P — Provocation / palliation (what makes it better or worse?)
  3. Q — Quality (describe the pain)
  4. R — Region / radiation (where, and does it move?)
  5. S — Severity (0–10 scale)
  6. T — Time (how long, how has it changed?)

Quick fire sample (15 of 16 on Quiz Me)

Patient care report: legal record of assessment, treatment, times, and disposition.
  1. influence
  2. Learning
  3. Minimum data set
  4. PCR / ePCR
Structured transition communication to hospital teams.
  1. Handoff (SBAR / I-PASS style)
  2. Learning
  3. SaCHART
  4. Narrative
Insider terms that confuse patients or allied staff.
  1. PCR / ePCR
  2. Jargon
  3. Closed-ended question
  4. Radio communication
Structured documentation framework emphasizing dispatch reason, response, assessment, transport.
  1. SaCHART
  2. Minimum data set
  3. DRAT
  4. Health information exchange (HIE)
Required chart elements for billing or reporting.
  1. Radio communication
  2. Digital signature
  3. Minimum data set
  4. Learning
Free-text story of the call with assessment and response.
  1. Open-ended question
  2. PCR / ePCR
  3. Narrative
  4. Jargon
Network-MLN/MLNProducts/Downloads.
  1. DRAT
  2. Health information exchange (HIE)
  3. Learning
  4. Narrative
Electronic sharing of patient data among authorized providers.
  1. DRAT
  2. Health information exchange (HIE)
  3. Open-ended question
  4. PCR / ePCR
Question answered with yes/no or a single fact.
  1. DRAT
  2. influence
  3. Jargon
  4. Closed-ended question
Structured voice reports on assigned channels with concise essential data.
  1. Radio communication
  2. Learning
  3. Reflective listening
  4. Jargon
Structured narrative format (example mnemonic): subjective, chief complaint, history.
  1. SaCHART
  2. Medical necessity
  3. DRAT
  4. Learning
Question inviting narrative description (for example, what happened today).
  1. Radio communication
  2. Open-ended question
  3. PCR / ePCR
  4. Digital signature
Clinical justification that transport or care aligns with patient needs and payer rules.
  1. Reflective listening
  2. Open-ended question
  3. Medical necessity
  4. Closed-ended question
Electronic attestation on ePCR.
  1. DRAT
  2. PCR / ePCR
  3. Medical necessity
  4. Digital signature
Patient-centered dialogue that builds rapport and gathers accurate information.
  1. Handoff (SBAR / I-PASS style)
  2. Closed-ended question
  3. Therapeutic communication
  4. Medical necessity

Some topics in this course differ across field references. See when sources disagree on Quiz Me before you teach from this sheet alone.

Full scored drills are on Quiz Me at /courses/nm-emt-b/chapters/04/print/. Answers are not marked on this sheet.