# Receiving/Giving pt. Reports



## Csybilly2003 (Feb 8, 2009)

I just started working for a company that is mainly used for medical transfers. Yesterday in my training i was receiving and giving pt. reports and i was having problems with that. If anyone has any suggestions for me i would love to hear them. Thank you.


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## mikie (Feb 8, 2009)

Practice makes perfect.


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## rhan101277 (Feb 8, 2009)

I gave my first report the other day to a doctor after a transfer from one hospital to the other.  The doctors comes to me and ask me for vitals, is blood pressure stable, etc.  I said his blood pressure was stable and he was alert and oriented, then i said he was a little bradycardia.  Which afterwards made me wonder if he thought i was stupid.  You either are or aren't.  He was right on the edge of being so with the pulse in the low 60's, so I thought I would mention it.  I know below 60 is considered bradycardia, but I was excited and in the moment oh well.  Maybe I sounded educated.


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## Sasha (Feb 8, 2009)

Practice practice practice. 

While your driving along in the car, pick the driver of one of the cars around you, make up some medical or trauma problems for him, and then give your report to yourself in the car. 

It's kinda fun if you can get creative with the problems. "Hyperroadragemia" was one of my favorites :]


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## BossyCow (Feb 8, 2009)

One of the best teaching tools for giving reports is the questions that you are asked by the receiving party. Those are the items you left out. Do that a time or two and embarrassment becomes your teacher. 

We have one ERT though that will always ask you for something weird. Bringing in a trauma pt and she'll ask if we did orthostatic pressures or what was their last meal.. not when.. what.... 

On the other extreme is a doc who only wants to hear age, gender and chief complaint. Nothing else, ever....


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## medicdan (Feb 8, 2009)

I learned to give good Triage reports fairly quickly because at the ER we feed to most often, the nurse will start taking to the patient if they dont like your report. It is also worth noting how the facility uses the information-- different hospitals note it differently in their software, so you need to give it in a specific order.  

I learned, at first, to write it down linearly on a notecard, with all the information in one place. It sounds something like this.

Good Morning. Here we have Mr. John Smith, age XX,  MRN/SSN 123-45-6789, coming from home complaining of abd pain. He ate a large lunch a few hours ago. The discomfort started 40 min later. Denies CP/SOB. His vitals are stable  (they dont need to know details, as my partner is getting a set on the hospital's machine at the same time). Hx of XXXX. He has an allergy to PCN, and is on X, X, X and X meds. We put him on X liters of O2. etc. 
Thats all they need to know. The nurse now knows what priority the patient is, and has the important info in the computer.

By the end, you should have gotten through SAMPLE and OPQRST.  

remember, you are your patient's advocate, and the immediate treatment they get is dependent on the quality, completeness, and conciseness of your report.


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## Veneficus (Feb 8, 2009)

BossyCow said:


> On the other extreme is a doc who only wants to hear age, gender and chief complaint. Nothing else, ever....



Just so you know some docs only want this information so they do not form biased judgments prior to seeing the pt themselves. (which is a good practice) they usually do look at the information you provide after so it is important to write as much as possible even if you are not asked for it, because once you leave, there is no practical way to get it.


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## MMiz (Feb 8, 2009)

Like others said, it just takes practice.  Some doctors/nurses want more complete reports than others.

I usually do a: "This is John Smith, a 65 y/o male complaining of... xxx."  A modified version of SAMPLE history, throw out the vitals, and then discuss our treatments.


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## rhan101277 (Feb 8, 2009)

Well this was a transfer so i wasn't really prepared for a report.  He asked me questions and I gave answers.  I did learn to be more prepared, they put him in a wheelchair and that was that.


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## Veneficus (Feb 8, 2009)

something i personally like in reports is things I can't readily see. If you bring in a patient who is telling somebody at a desk their SSN telling me they are A&O is sort of redundant.


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## BossyCow (Feb 8, 2009)

Veneficus said:


> Just so you know some docs only want this information so they do not form biased judgments prior to seeing the pt themselves. (which is a good practice) they usually do look at the information you provide after so it is important to write as much as possible even if you are not asked for it, because once you leave, there is no practical way to get it.



Just so you know, I already knew that. Was just providing examples of the opposite ends of the spectrum.  Too often new EMTs are told that "This is the way it's done" and "You must do it this way only to find that different facilities, different docs, different systems do things very differently.

The doc I mentioned is my husband's fishing/hunting buddy.


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## TransportJockey (Feb 8, 2009)

Practice practice practice.

when I worked for an IFT company, my first six months there I was an attend only. That mean 8-9 reports every shift, 4 days a week, at least. Giving report became second nature after a few weeks.

The more nerve wracking calls were ones from 'SNFs' that should have been 911 calls, but they didn't want to hurt their stats. That meant a radio report to the facility and a report to the RN taking the pt and maybe MD/PA


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## Ridryder911 (Feb 8, 2009)

Usually radio reports are to be given in a short precise manner, the main emphasis to forewarn the ED of what is coming in to prepare them. What room can be available, resources needed, and to mainly prepare for the patient. All of this can be done in <1 minute. 

Upon arrival; I personally give a hx similar to what physicians give to each other. 

Age/Consciousness, Sex

IPHX- what occurred, C/C, etc. i.e MVA, Chest pain for 2 hours.

PMHX Brief specific-cardiac, COPD, CA, etc.

Physical Findings- usually specific or negative. i.e. bruising chest wall, but good lung sounds in all fields, as well as heart tones clear. 

Tx EMS and PTA ECG to med.'s

Results or changes 

All of this can occurr within a few minutes. 

I have found to use specific terms but be sure it is accurate and pronounced accurately. Simple terms if one does know them. It is much beter to use such than to be thought as foolish and not as to depend upon . 

As many others describe practice makes perfect. 

R/r 911


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## emtfarva (Feb 8, 2009)

It takes time. I give reports to nursing home all the time. Sometimes they listen sometimes they don't. I still give a report. Early this morning I took my first GSW to Boston and I got to give report twice. I gave it to traige and then to the Pt's nurse and doctors. It was kinda fun. They even let me take a look at it. I have been doing this for Two years and I still get flustered on 911 calls. What I have learned is if the hosp wants some info from you they will ask you. Otherwise I just give a short report. It goes like this:

This Mr. So and So, who is 39 y/o m c/o (whatever). (PMHx) and meds. Last known VS. And anything I think is important that the Hosp should know. If it is a Hosp to Hosp transfer I will also tell them any interventions that the sending Hosp might have done.

I have also learned that when doing a Radio patch they like it short and sweet. I usally tell them the Age, sex, cc, I tell them that VS are wnl if they are or tell them VS if they abnormal. Then eta and ask if they have any questions. I will tell them if I did any interventions also.


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## Sasha (Feb 8, 2009)

> They even let me take a look at it



You should have looked at it when you picked the patient up.


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## emtfarva (Feb 8, 2009)

Sasha said:


> You should have looked at it when you picked the patient up.



not when it was splinted and wrapped for the transport. I came from another hosp. ^_^


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## Sasha (Feb 8, 2009)

emtfarva said:


> not when it was splinted and wrapped for the transport. I came from another hosp. ^_^



When I did IFT we were still expected to look at the wound to document in our report, then redress.


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## TransportJockey (Feb 8, 2009)

Sasha said:


> When I did IFT we were still expected to look at the wound to document in our report, then redress.



The one exception we had was if it was plastered. Then we were just to leave it


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## emtfarva (Feb 8, 2009)

Sasha said:


> When I did IFT we were still expected to look at the wound to document in our report, then redress.



the sending hosp would kill me if I did that. Anyway if it is bleeding I would never take the previous bandage off just in case it was trying to clot. I get a report from the nurse. They tell me what it looks like. Plus I don't have Xray vision and I wouldn't have been able to tell that the ulna was broken with fragments by taking off the bandage and rewraping it. When I do write it in my report I add the words per nsg staff.


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## Sasha (Feb 8, 2009)

emtfarva said:


> the sending hosp would kill me if I did that. Anyway if it is bleeding I would never take the previous bandage off just in case it was trying to clot. I get a report from the nurse. They tell me what it looks like. Plus I don't have Xray vision and I wouldn't have been able to tell that the ulna was broken with fragments by taking off the bandage and rewraping it. When I do write it in my report I add the words per nsg staff.



You don't need to know what the ulna looked like or if it was broken to look at the wound, here you were expected to document the size and shape of the wound, then redress.


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## emtfarva (Feb 8, 2009)

Sasha said:


> You don't need to know what the ulna looked like or if it was broken to look at the wound, here you were expected to document the size and shape of the wound, then redress.



by looking at the wound, are you giving more of a chance that the wound will become infected? I was taught not to remove a bandage from a wound. I was trained to only treat and control bleeding not to redress a bandage. Plus if I did that It would have taking more than the 20 min I was onsence. (I was waiting for paperwork and a report. who would knew that the er was going to be busy at 02:30 on a sunday.) I would have to take the ace bandage off. take the 4" kling off and replace the abd. next I would also be moving the Pt's arm around since it was in a cast to keep the it imbolized. (orthoglass). I try transport my Pt's with min. amount of pn. It is better that way. And even it started to bleed through all that, I will still leave it there and add more bandage.


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## marineman (Feb 8, 2009)

Back on topic momentarily here's my method for giving a report. We get a bunch of information from dispatch, the patient, family, bystanders etc. I collect all that information and first thing I do is filter out the garbage. Once you're down to the bare essentials put the information in a logical order so the things that are most pertinent to the patients condition come out first while the nurse might still be listening. You want to be brief and to the point but most of the hospitals we go to like a more detailed report so we have to keep a perfect balance.

I think rid said it before but another good thing to remember is: patient demographics, what's wrong with patient, vital signs before treatment, what did you do, response to treatment and vital signs after treatment, ETA. To the best of my knowledge nobody has ever been fired for giving too much information and the nurse will ask questions if you don't give enough. 

If you have a pocket guide mine has a guide to radio reports on the inside of the front cover that walks you through a pretty decent report just make sure you have all the information before you start trying to give a report.


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## Laur68EMT (Feb 9, 2009)

Our ER actually provided us with a copy of what they want from incoming squads. They want:

Our squad
Patients age
Sex
CC
BP, Respirations, Pulse
Any important relevant info (CHF, LOC, etc)
Approx ETA 

and that's about it.

Sidenote to emtfarva: We also do not remove a bandage to look at the wound. If it's dressed, it stays that way til a doctor or nurse removes it at the hospital.  We can add more but we do not take it away.


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## emtfarva (Feb 9, 2009)

Sidenote to emtfarva: We also do not remove a bandage to look at the wound. If it's dressed, it stays that way til a doctor or nurse removes it at the hospital.  We can add more but we do not take it away.

That is the way I see it.


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## mikeN (Feb 11, 2009)

I take bandages off now. I went to a nursing home to pick up a PT that 'bumped their head' from an unwitnessed fall.  I thought the dressing seemed a bit excessive so I wanted to see this bump. The facility didn't want us seeing he had a nice laceration above his eye. Had I not looked at that I wouldhave looked like a fool when giving a report at the ED. Then again it's depends on the call.


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## emtfarva (Feb 11, 2009)

mikeN said:


> I take bandages off now. I went to a nursing home to pick up a PT that 'bumped their head' from an unwitnessed fall.  I thought the dressing seemed a bit excessive so I wanted to see this bump. The facility didn't want us seeing he had a nice laceration above his eye. Had I not looked at that I wouldhave looked like a fool when giving a report at the ED. Then again it's depends on the call.



I always look at a wound at a nuring home if they are going to the ER for eval. This was a Hosp to Hosp transfer.


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## mikeN (Feb 11, 2009)

hospital to hospital.  Screw that then, I'll leave the dressings on.


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## BossyCow (Feb 12, 2009)

You can tell if a wound needs redressing because it will bleed through. If there is no blood leaking through the current dressing, why mess with it? The only time I've ever messed with an existing dressing was if it was falling off or in wilderness settings where repeated examination of the wounds is required.


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## HokieEMT (Feb 16, 2009)

When it comes to giving reports to the nurse who is in charge of the pt I basically say to her what I am going to or have written in my report. As we all know that report is a giant CYA so it is gonna give the nurse and the other caregivers everything they need to know.
With the charge nurse at the recieving area its just a really quick who it is and what is the CC.  This is so they can determine where they are gonna put them.
When it comes to radio reports it's basically a short and sweet version of my written report.
"I am currently en-route to your facility with priority X XX year old male/female complaining of ________ their current vitals are ...  We arrived to find the patient...  We have established an IV with XXX currently pushed and (any other interventions).  We are approx XX minutes from your facility see you upon arrival if there are any developments we will recontact."


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## Airwaygoddess (Feb 16, 2009)

*Patient care report*

Is this a radio report or is this the patient care report on the transfer of care at the bedside?


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## HokieEMT (Feb 16, 2009)

The bit in quotation marks is the radio report while en-route to an ER from a call.  This is regular 911 calls not hospital to hospital stuff.  Where I run it is required on all Priority 1 and 2 pts that you call the ER on your portable radio which is in my area a Motorola 800Mhz XT-4000.  While it is not required for Priority 3 pts some people like myself do it anyways.


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## mycrofft (Feb 16, 2009)

*Lotsa good tips, espcially the old hands above.*

 Be the receiver's scout, not his Daily Planet reporter.


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## frogtat2 (Feb 19, 2009)

I think everyone has trouble learning how to give reports.  I would write mine down so I would remember everything I wanted/needed to say.  

Just practice.  You will find what works for you.


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## Jon (Feb 19, 2009)

I aim to have my radio/cell phone reports for NOTIFICATION be <30 seconds...


  Them: XXXX Emergency: Command or notification? (or Physician or Nurse?)

  Me: Notification

  Them: OK… go ahead.

This is Jon with XXXX EMS, ALS / BLS  notification. We are coming to you with a XX year old (fe)male from (Work, residence, XXX nursing home). Patient complains of ____________. Vitals are stable or ______ (if unstable). (If calling in for my paramedic, let them know that, and perhaps what he is working on for care. Give ETA, and any requests. We’ll have further report at bedside. Do you copy?




  One recent one:

  This is Jon with XXX EMS. ALS Notification. We are coming to you with an 88 year old female from XXXX Nursing Home. Patient is having severe respiratory distress, rales throughout, pulseox’ing in the 90’s on nonrebreather. Patient is on CPAP with minimal improvement. The paramedic is attempting to get IV access. We’ll see you in 5 minutes and we will need Respiratory standing by in the ED. Do you copy?

  Alright, we’ll see you in 5 and we’ll page respiratory.



  Now when I call for command – I’m going to give a reasonably full report… Chief complaint, Vitals, relevant physical exam, and WHY I’m calling the doc:
  Are you ok with me bringing this to your facility? (for stuff that is borderline trauma criteria because patient fell down and is on Wafarin).
  Patient wants to refuse further care and is CAOx4

  Let them say their piece…. Answer their questions...

  Command calls take time.


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## Aidey (Feb 19, 2009)

For radio reports I use the format that the county I work in has outlined for us. If my report is more than 20-30 seconds something is seriously wrong, or it's a STEMI patient and I'm justifying activating the Cath team. 

If there is one thing I've learned about radio reports it is that the nurses WILL walk away from the radio if you take too long or start rambling off stable vitals; their whole list of meds; or all their allergies. Unless that information is 110% necessary for them to know ahead of time, don't say it on the radio. 

Bedside reports I tend to do similar to what Rid outlined. I've noticed with doctors, especially the busy ones, if you present the information in an organized manner they are familiar with they tend to listen to you more.


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## TransportJockey (Feb 19, 2009)

You people are lucky that a facility will just take your word for vitals. Almost every ER in ABQ will ask you what the vitals ARE if you just tell them 'stable'


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## johnrsemt (Feb 20, 2009)

In Indianapolis where I was trained and worked for 10 years;  at the bigger hospitals we gave the quick:  age, sex, cc, and treatments, and GCS and just on critical patients.  Most of the hospitals didn't care unless you were doing CPR or they were bleeding out..
  In utah where I am now, they want a detailed report.  had a nurse ask me on the phone for all of the patients vital signs, during the entire transport:L  2 patients 1hr 35min transport.   the report took me 12 minutes, and I was 15 out when I called them:  when I arrived at the ER they got mad cause I only gave them 2-3 min to get ready for them.           The patients both had BLS knee injuries

go figure


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## bittner (Mar 1, 2009)

Practice does make perfect.  I have been working as a basic for 2 yrs.  I usually give my reports just about the same.  It all comes natural now.  Here is an example.

Medic 6 to (Hospital)
Yes, We are currently enroute to your facility with a (age)(m/f) for the services of (ER doctor or specific doctor).  Chief Complaint today is going to be (c/c). At this time the pt is (A&O x ___ with a GCS of ____).  Have patient in the position of comfort with O2 via nasal cannula at a rate of____....( treatment..etc).  BP is ____, HR_____ RR_____  and O2sat_____on Room Air or O2.  We have an ETA of ________ any further questions.

Medic 6 out.


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## Ridryder911 (Mar 1, 2009)

johnrsemt said:


> In Indianapolis where I was trained and worked for 10 years;  at the bigger hospitals we gave the quick:  age, sex, cc, and treatments, and GCS and just on critical patients.  Most of the hospitals didn't care unless you were doing CPR or they were bleeding out..
> In utah where I am now, they want a detailed report.  had a nurse ask me on the phone for all of the patients vital signs, during the entire transport:L  2 patients 1hr 35min transport.   the report took me 12 minutes, and I was 15 out when I called them:  when I arrived at the ER they got mad cause I only gave them 2-3 min to get ready for them.      The patients both had BLS knee injuries go figure



In most real world, after the first 30 seconds you would had been talking to dead air. Does their staff have nothing more to do? 

You are going to give formal one upon arrival and a written one after that, redundantly redundant.


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## PapaBear434 (Mar 1, 2009)

Our new radios piss me off.  My reports have never been THAT long, but they have been set to automatically cut off after three seconds.  Combine that with the fact that it's set to make you wait three seconds after you depress the switch before it keys in to prevent us from stepping on each other, you have about twelve seconds to lay out a report before the "BEEP BEEP" comes.  You have to let go, rekey (another three seconds) and continue.  

End result is that your reports come out sounding broken and disjointed.  Even the most experienced medics are complaining about the things, and everyone is just buying their own personal radios to not have to deal with it.


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## MRE (Mar 2, 2009)

You would have to be a bit carefull with this, but you could probably take the radio to a dealer that does programming and have them remove the delay and the transmit timeout.  You might even be able to get them to do it for cheap or free seeing as they don't have to sit and enter frequencies.  You would just need to weigh the possibility of your agency finding out and having a problem with it.  Personally I wouldn't think twice about doing it, the way my service works, but i'm sure many others are different.



PapaBear434 said:


> Our new radios piss me off.  My reports have never been THAT long, but they have been set to automatically cut off after three seconds.  Combine that with the fact that it's set to make you wait three seconds after you depress the switch before it keys in to prevent us from stepping on each other, you have about twelve seconds to lay out a report before the "BEEP BEEP" comes.  You have to let go, rekey (another three seconds) and continue.
> 
> End result is that your reports come out sounding broken and disjointed.  Even the most experienced medics are complaining about the things, and everyone is just buying their own personal radios to not have to deal with it.


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## PapaBear434 (Mar 2, 2009)

W1IM said:


> You would have to be a bit carefull with this, but you could probably take the radio to a dealer that does programming and have them remove the delay and the transmit timeout.  You might even be able to get them to do it for cheap or free seeing as they don't have to sit and enter frequencies.  You would just need to weigh the possibility of your agency finding out and having a problem with it.  Personally I wouldn't think twice about doing it, the way my service works, but i'm sure many others are different.



Unfortunately, no.  The department wants us to do this so that we don't step on each other and tie up the radio unnecessarily.  This was on purpose...  I didn't know either of these was an issue, honestly.


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## MRE (Mar 2, 2009)

PapaBear434 said:


> Unfortunately, no.  The department wants us to do this so that we don't step on each other and tie up the radio unnecessarily.  This was on purpose...  I didn't know either of these was an issue, honestly.



If the dept wants your radios to have the delayed key-up and timeout, then would they let you use your own radio that was not equipped with that feature?

Also, you may have mentioned this, but is your service fire/ems?  If it is, then the relatively short transmissions might be ok for relaying directions and such for fire and dispatch purposes, which might be all that the dept looked at when ordering radios.  They might have overlooked the EMS side and the longer reports that we do.  You could probably appeal to them to have your radio changed (maybe add a few things about the receiving hospital not being able to understand you, and the detriment the radios are to good patient care)  That might get you somewhere.


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## PapaBear434 (Mar 2, 2009)

W1IM said:


> If the dept wants your radios to have the delayed key-up and timeout, then would they let you use your own radio that was not equipped with that feature?
> 
> Also, you may have mentioned this, but is your service fire/ems?  If it is, then the relatively short transmissions might be ok for relaying directions and such for fire and dispatch purposes, which might be all that the dept looked at when ordering radios.  They might have overlooked the EMS side and the longer reports that we do.  You could probably appeal to them to have your radio changed (maybe add a few things about the receiving hospital not being able to understand you, and the detriment the radios are to good patient care)  That might get you somewhere.



We can use our own personal radios, but I'm not really into paying that much for one right now.  But no, we are an all EMS service.  This was a decision passed down from on high.


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## TransportJockey (Mar 2, 2009)

You use your handheld to call reports to the local EDs? When I worked for the local service, our handhelds were truck to truck or to dispatch. We had a separate med radio in the back to talk to the EDs in the city


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## PapaBear434 (Mar 2, 2009)

jtpaintball70 said:


> You use your handheld to call reports to the local EDs? When I worked for the local service, our handhelds were truck to truck or to dispatch. We had a separate med radio in the back to talk to the EDs in the city



We have a separate CORE radio, but I've never used them.  Nor do I even know how, for that matter.  We just use the 800 in the truck, or we can use our portables on our hip by changing the band.


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## EMTstaroflife (Mar 10, 2009)

*I understand....*

When I obtained my certification in SC as an EMT-B I NEEDED a job and i needed a job fast, so I started out working for a non-emergent Transport Service.  I understand the feeling you talk about during your transport.  We did transports for pt leaving a hospital and going to a Rehab hospital which was only .7 mile away.  By the time is loaded the pt, got my stephoscope, and BP cuff we were at the hospital.  So what info did I have to give to the receiving hospital...ummm not much.  Half of the time I didn't even have time to read the discharge paper work.  Needless to say, I didnt get better at giving and receiving reports until I started working in 911 service about a year ago.  

    I've now been a Basic for one year and currently in Paramedic School.  My reports have gotten better but I still struggle sometimes.  I start ride time this week so sink o swim, ready or not, here I am.  I am learning to use the acronym (Priority)CC-MOI/NOI-LOC-ABCDE-V/S-interventions-ETA

Priority-Emergent/Non-Emergent
Chief Complaint
mechanism of injury/nature of illness
Loss of Consciousness/Level of Consciousness(AVPU)
Airway
Breathing
Circulation
Disability
Expose
Vital Signs
Interventions(what i did to help pt/improve/worsen)
Estimated Time of Arrival

I am a believer of think twice act once and also Think smarter, not harder.  If you can incorporate what you already do to assess your patient and give a shorter more concise version that might help.


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## AJ Hidell (Mar 10, 2009)

PapaBear434 said:


> We have a separate CORE radio, but I've never used them.  Nor do I even know how, for that matter.


Just for the sake of technical and historical accuracy, that is COR, not CORE.  It's Motorola's brand name for the old orange Coronary Observation Radio.  The newer (late 70's and beyond) white models were the APCOR, or Advanced Portable Coronary Observation Radio.  There were several models of each.  And if it's not Motorola, then it is technically neither a COR nor an APCOR.


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## PapaBear434 (Mar 10, 2009)

AJ Hidell said:


> Just for the sake of technical and historical accuracy, that is COR, not CORE.  It's Motorola's brand name for the old orange Coronary Observation Radio.  The newer (late 70's and beyond) white models were the APCOR, or Advanced Portable Coronary Observation Radio.  There were several models of each.  And if it's not Motorola, then it is technically neither a COR nor an APCOR.



True enough, but our radios are actually labeled with a big "CORE" sticker.  I don't know if someone didn't know what you just pointed out or what.  And I'll be honest and out myself: I never knew what it stood for.  I knew what it was for, theoretically, but never bothered to learn the background.

Either way, what you said, but we don't use them.  They trust our medics to read the three/four lead, and though they trust them to read a twelve lead the LifePack as a built in transmitter, so no hooking up to a radio is necessary.

I imagine most people run it this way these days.  At least in any non-rural area, anyway.


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## mikeN (Mar 12, 2009)

try to observe in an ED or become a tech in an ED. You'll see BLS and ALS give reports so you'll know what info the nurses need to know and what questions they'll probaably ask. It's been helpful for me improving my reports.


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