Case Study: Communications and Documentation

Case Study: Communications and Documentation

• An 86-year-old woman fell into her bathtub at 3 AM.
• She remained in the bathtub until 10 AM.
• She is sitting in the bathtub, back on the faucet, without water.
• Patient is pale and cold to the touch.
• Patient reports severe hip and back pain (8/10 and 10/10, respectively, on a 1-10 scale).
• The patient's blood pressure is 112/84, pulse is 72, and respirations are 14.
• Crepitus was noted in the pelvic girdle.
• Patient is conscious and alert.
• Patient has a history of diabetes.
• The paramedics immobilized the patient with a c-collar.
• ETA to the hospital is 10 minutes.

Pre-Arrival Radio Report

• The pre-arrival report should include important information to assist the receiving hospital with patient care.
• This needs to include, but is not limited to: patient's condition, presenting complaints, vital signs, pertinent past medical history.

Importance of Narrative Documentation

• Narrative reports are more detailed than check boxes and better describe the situation.
• They provide context about patient presentation, which can be crucial for the receiving hospital personnel.

Therapeutic Communication Techniques

• Addressing patient's pain and fear during the call may improve patient outcomes.
• Employing empathetic communication minimizes the potential for miscommunication.
• Offering reassurance and validating the patient's feelings is critical.
• Direct eye contact and adjusting the tone of voice and sentence structure may assist understanding.

Report to the Hospital

• The report should include:
  • The name of the ambulance service (Columbus Fire)
  • The destination hospital (Columbus Community Hospital)
  • Patient's age and sex
  • Time of incident.
  • Patient's current status
  • The patient's pain level.
• Include important details like vital signs, and any injuries (crepitus in pelvic girdle).