Unit 5: Operations
Communication & Documentation
Clear communication and accurate documentation are essential responsibilities of every Emergency Medical Technician (EMT). Whether speaking with a patient, providing a hospital report, or completing a patient care report (PCR), EMTs must communicate important information clearly and accurately. This NREMT study guide lesson covers patient communication, radio reports, transferring care, and EMS documentation. Five EMT practice questions with detailed explanations will help you review these important skills.
Effective communication helps EMTs obtain information, coordinate treatment, and ensure continuity of patient care. Accurate documentation records the patient’s condition, treatments provided, and response to care.
Communicating With Patients
EMTs should communicate clearly, calmly, and respectfully during patient care.
Important techniques include:
- Introduce yourself and explain your role.
- Use simple language instead of unnecessary medical terminology.
- Listen carefully and ask open-ended questions.
- Explain procedures before performing them when possible.
- Respect the patient’s privacy and cultural differences.
- Maintain a calm, professional manner.
For example, asking "Can you describe how you’re feeling?" may provide more useful information than a question requiring only a yes-or-no answer.
Overcoming Communication Barriers
Some patients have difficulty communicating because of language differences, disabilities, medical conditions, or altered mental status.
Adapt communication methods to the patient’s needs:
- Hearing impairment: Face the patient and use written communication or appropriate assistive services when necessary.
- Language differences: Use a qualified medical interpreter when available.
- Visual impairment: Identify yourself and explain procedures before assisting the patient.
- Confusion or cognitive impairment: Use short explanations and allow additional time for responses.
- Children: Use age-appropriate language and involve caregivers when appropriate.
Never assume that a patient who has difficulty communicating cannot understand what is happening.
Communication With Dispatch and EMS Personnel
Dispatchers provide information about emergency locations, reported illnesses or injuries, patient numbers, and potential safety concerns.
EMTs should communicate important changes, including additional patients, safety hazards, or requests for specialized resources.
Radio communications should be brief, professional, and easy to understand.
Closed-loop communication helps EMS teams avoid misunderstandings.
It involves three steps:
- One provider gives a clear instruction.
- The receiving provider acknowledges or repeats it.
- Completion of the task is confirmed.
For example, when asked to obtain a blood pressure, an EMT acknowledges the instruction, takes the measurement, and reports the result.
This technique is particularly useful during emergencies involving multiple responders.
Hospital Reports and Patient Handoffs
EMTs must communicate essential patient information to the receiving medical facility.
A hospital radio report or verbal handoff should include:
- Patient information: Approximate age and relevant identifying details.
- Chief complaint: The primary reason for the emergency response.
- Medical history: Pertinent conditions, medications, or allergies.
- Assessment findings: Level of consciousness, symptoms, injuries, and vital signs.
- Treatment: Interventions performed and the patient’s response.
- Transport information: Changes in condition and estimated time of arrival when appropriate.
For example, a suspected stroke report should include the patient’s neurological findings and last known well time.
At the hospital, provide an organized verbal handoff and allow the receiving healthcare professional to ask questions.
A clear handoff helps prevent important information from being overlooked.
Follow agency procedures for formally transferring responsibility for patient care.
Patient Care Reports (PCRs)
A patient care report (PCR) is the official record of the patient’s assessment, treatment, and transport.
Most EMS agencies use an electronic patient care report (ePCR) system.
A complete report generally includes:
- Dispatch and response information.
- The patient’s chief complaint and relevant medical history.
- Assessment findings and vital signs.
- Treatments and medications administered.
- The patient’s response to treatment.
- Significant changes and reassessment findings.
- Transport and transfer-of-care details.
Documentation should be accurate, complete, and completed promptly according to agency requirements.
Objective Documentation
EMTs must document facts without introducing unsupported assumptions or personal opinions.
For example:
Poor documentation: "The patient was drunk and uncooperative."
Better documentation: "The patient had slurred speech, an odor of alcohol on the breath, and repeatedly declined to answer assessment questions."
The second statement describes observable findings rather than assuming a diagnosis.
Important documentation principles include:
- Record information accurately and objectively.
- Use approved medical terminology and abbreviations.
- Include relevant positive and negative findings.
- Document treatments and patient responses.
- Record significant changes in the patient’s condition.
- Use the patient’s own words when appropriate.
If an error is discovered, follow agency procedures for correcting the report. Never falsify information or improperly alter previous documentation.
Patient Confidentiality
EMTs must protect confidential patient information.
The Health Insurance Portability and Accountability Act (HIPAA) establishes federal protections for medical information handled by covered entities.
EMTs should not discuss patient information with unauthorized individuals or post patient details on personal social media accounts.
However, HIPAA generally permits sharing relevant patient information with other healthcare providers for treatment purposes, including hospital handoffs.
Follow agency policies and applicable privacy laws when handling patient information.
Key Tip
Communicate clearly, document objectively, and never assume important information has already been shared. A concise hospital report, organized patient handoff, and accurate patient care report help ensure continuity of care throughout the emergency response.