Assessment & Critical Care · Chapter 8 Not started

Communications and Documentation

Radio discipline, clean handoff reports, and records that protect patients and patrollers.

Key points

Radio basics: think before keying, identify who you're calling then yourself, keep it brief and plain-language, and never transmit a patient's name.
A good handoff report covers age/sex, chief complaint, mechanism, findings, vitals with trends, and care given — delivered in under a minute.
Document what you saw, did, and how the patient responded; if it isn't written down, it's hard to prove it happened.
Incident reports are legal documents: objective, factual, complete, and signed. Correct errors with a single line-through, never erasure.
Patient information is confidential — share it only with those involved in care or as required by law.
Refusals need documented capacity, explained risks, and a witnessed signature.

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