10 hours ago There are seven elements (at a minimum) that we have identified as essential components to documenting a well written and complete narrative. 1. Dispatch & Response Summary. The dispatch and response summary provides explicit details of where the unit was dispatched, what they were dispatched for and on what priority. >> Go To The Portal
These are pertinent points that should be included in hospital radio reports: Unit’s identification and level of service (ALS or BLS) Patient’s age and gender
Hospitals radio reports should be about 30 seconds in length and give enough patient information for the hospital to determine the appropriate room, equipment and staffing needs. Parts of the EMS radio report to the hospital These are pertinent points that should be included in hospital radio reports:
Here is an example of a concise and informative radio report: “Community hospital, this is Ambulance 81. We are currently en route to your facility with a 72 y/o male who fell approximately 20 feet from a roof. Patient is conscious, alert and oriented to person, place, time and events. Patient denies any loss of consciousness.
Communication with medical direction may be at the receiving hospital, or it may be at a service-designated medical facility that is not receiving the patient. However, the components of being organized, clear, concise and pertinent fit into all types of radio communication.
The EMS radio report to the hospital done well communicates vital information to help the hospital prepare for the patient's arrival “Community hospital, this is Herb in Ambulance 81. We are on the way to your place with an old man named Joe John who fell. They’ve used a spineboard to move him to the cot.
The intent of the hospital radio report is to give the receiving hospital a brief 30-second “heads up” on a patient that is on the way to their emergency department. It should be done over a reasonably secure line and in a manner that does not identify the patient.
Communication policies developed by EMS agencies should include guidelines for appropriate radio and verbal patient reporting to hospitals. Hospital radio reporting is a skill that should be practiced by new EMTs and critiqued as a component of continuing education and recertification.
Hospitals radio reports should be about 30 seconds in length and give enough patient information for the hospital to determine the appropriate room, equipment and staffing needs.
This article, originally published June 16, 2008, has been updated. Contributing author Larry Torrey is a paramedic and emergency department RN from Maine with more than 20 years of experience as a nurse, medic and instructor. He currently works in a Boston trauma center, and with several other prehospital endeavors.
Julie K. (Jules) Scadden, NREMT-P, PS has been actively involved in EMS for 18 years, and is the CQI/IT/Data Coordinator with Sac County Ambulance Service in Northwest Iowa. A passionate advocate for EMS, Jules has served on numerous advisory boards and committees on state and national levels. She is one of the founders and past Secretary for the National EMS Museum Foundation and is currently serving as the President of the Iowa CPR Education Foundation and the Board Secretary of the National EMS Memorial Bike Ride, Inc. ("Muddy Angels"). Jules is an EMS Instructor serving as adjunct faculty for areas community colleges and is a frequent presenter at EMS conferences speaking on topics covering special patient populations and Children with Special Challenges. Jules is a co-author of Fundamentals of Basic Emergency Care, 3rd edition.
Communication with medical direction may be at the receiving hospital, or it may be at a service-designated medical facility that is not receiving the patient . However, the components of being organized, clear, concise and pertinent fit into all types of radio communication.
Jules is an EMS Instructor serving as adjunct faculty for areas community colleges and is a frequent presenter at EMS conferences speaking on topics covering special patient populations and Children with Special Challenges. Jules is a co-author of Fundamentals of Basic Emergency Care, 3rd edition. Tags.
Consent and Authorization Forms: Consent for treatment: For any course of treatment that is above routine medical procedures, the physician must disclose as much information as possible so the patient may make an informed decision about his/her care. This information should include: Diagnosis and chances of recovery.
A medical record is a systematic documentation of a patient’s medical history and care. It usually contains the patient’s health information (PHI) which includes identification information, health history, medical examination findings and billing information. Medical records traditionally were kept in paper form, with tabs separating the sections.
Progress notes include new information and changes during patient treatment. They are written by all members of the patient’s treatment team. Some of the information included in progress notes includes: Observations of the patient’s physical and mental condition. Sudden changes in the patient’s condition.
Physician’s orders for the patient to receive testing, procedures or surgery including directions to other members of the treatment team. Prescriptions for medications and medical supplies or equipment for the patients home use.
Release of information: Identity verification such as a driver’s license. A description of the information to be used or disclosed. The name of the person or organization authorized to disclose the information. The name of the person or organization that the information is to disclosed.
Disclosures made regarding a patient’s protected health information without their authorization is considered a violation of the Privacy Rule under HIPAA. Most privacy breaches are not due to malicious intent but are accidental or negligent on the part of the organization.