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EMT Basic · Chapter 4 · Review · Chapter track

Communications and Documentation

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

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)

Chapter web resources

Optional reading from authoritative sites. Your textbook remains the primary source for this course.

When sources disagree (5 topics to verify before you teach from this chapter alone)

Printable study sheetPrintable flashcards (PDF, 10-up)Read first, then practise the track.

Showing Chapter track material. Switch tracks on the chapter page.

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.

    SourcePrinted pages 117–163. Emergency Care and Transportation of the Sick and Injured, 12th ed., Jones & Bartlett Learning / American Academy of Orthopaedic Surgeons (AAOS)

  • Digital signature

    Electronic attestation on ePCR. Utilization: Legal validity per agency system.

    SourcePrinted pages 117–163. Emergency Care and Transportation of the Sick and Injured, 12th ed., Jones & Bartlett Learning / American Academy of Orthopaedic Surgeons (AAOS)

  • DRAT

    Structured documentation framework emphasizing dispatch reason, response, assessment, transport. Utilization: Another structured narrative style referenced in modern EMS documentation teaching.

    SourcePrinted pages 117–163. Emergency Care and Transportation of the Sick and Injured, 12th ed., Jones & Bartlett Learning / American Academy of Orthopaedic Surgeons (AAOS)

  • Handoff (SBAR / I-PASS style)

    Structured transition communication to hospital teams. Utilization: Reduces missed allergies, interventions, and pending problems.

    SourcePrinted pages 117–163. Emergency Care and Transportation of the Sick and Injured, 12th ed., Jones & Bartlett Learning / American Academy of Orthopaedic Surgeons (AAOS)

  • Health information exchange (HIE)

    Electronic sharing of patient data among authorized providers. Utilization: May inform destination care; still verify identity and respect privacy limits.

    SourcePrinted pages 117–163. Emergency Care and Transportation of the Sick and Injured, 12th ed., Jones & Bartlett Learning / American Academy of Orthopaedic Surgeons (AAOS)

  • Jargon

    Insider terms that confuse patients or allied staff. Utilization: Translate for patient understanding.

    SourcePrinted pages 117–163. Emergency Care and Transportation of the Sick and Injured, 12th ed., Jones & Bartlett Learning / American Academy of Orthopaedic Surgeons (AAOS)

  • Learning

    Network-MLN/MLNProducts/Downloads

    SourcePrinted pages 117–163. Emergency Care and Transportation of the Sick and Injured, 12th ed., Jones & Bartlett Learning / American Academy of Orthopaedic Surgeons (AAOS)

  • 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.

    SourcePrinted pages 117–163. Emergency Care and Transportation of the Sick and Injured, 12th ed., Jones & Bartlett Learning / American Academy of Orthopaedic Surgeons (AAOS)

  • Minimum data set

    Required chart elements for billing or reporting. Utilization: Completeness prevents downstream administrative failure.

    SourcePrinted pages 117–163. Emergency Care and Transportation of the Sick and Injured, 12th ed., Jones & Bartlett Learning / American Academy of Orthopaedic Surgeons (AAOS)

  • Narrative

    Free-text story of the call with assessment and response. Utilization: Must match times, vitals, and treatments recorded elsewhere.

    SourcePrinted pages 117–163. Emergency Care and Transportation of the Sick and Injured, 12th ed., Jones & Bartlett Learning / American Academy of Orthopaedic Surgeons (AAOS)

  • Open-ended question

    Question inviting narrative description (for example, what happened today). Utilization: Starts interviews and elicits the patient's concerns without leading.

    SourcePrinted pages 117–163. Emergency Care and Transportation of the Sick and Injured, 12th ed., Jones & Bartlett Learning / American Academy of Orthopaedic Surgeons (AAOS)

  • PCR / ePCR

    Patient care report: legal record of assessment, treatment, times, and disposition. Utilization: Complete promptly with objective findings, narrative, and signatures per policy.

    SourcePrinted pages 117–163. Emergency Care and Transportation of the Sick and Injured, 12th ed., Jones & Bartlett Learning / American Academy of Orthopaedic Surgeons (AAOS)

  • 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.

    SourcePrinted pages 117–163. Emergency Care and Transportation of the Sick and Injured, 12th ed., Jones & Bartlett Learning / American Academy of Orthopaedic Surgeons (AAOS)

  • Reflective listening

    Restating or summarizing the patient's words to confirm understanding. Utilization: Builds trust and reduces misunderstandings during emotional distress.

    SourcePrinted pages 117–163. Emergency Care and Transportation of the Sick and Injured, 12th ed., Jones & Bartlett Learning / American Academy of Orthopaedic Surgeons (AAOS)

  • SaCHART

    Structured narrative format (example mnemonic): subjective, chief complaint, history. Utilization: Helps organize charting when your agency adopts structured narrative models.

    SourcePrinted pages 117–163. Emergency Care and Transportation of the Sick and Injured, 12th ed., Jones & Bartlett Learning / American Academy of Orthopaedic Surgeons (AAOS)

  • 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.

    SourcePrinted pages 117–163. Emergency Care and Transportation of the Sick and Injured, 12th ed., Jones & Bartlett Learning / American Academy of Orthopaedic Surgeons (AAOS)

Sequences · 2

  • SAMPLE history — Order the components of the SAMPLE history mnemonic.
  • OPQRST pain assessment — Order the OPQRST questions for assessing pain or discomfort.