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EMS Communication and Documentation: Essential Skills for Quality Patient Care

Effective communication and accurate documentation are foundational skills for every EMS provider. Patient care does not begin when treatment is started—it begins the moment information is received from dispatch and continues through scene interaction, transport, handoff, and final written documentation.

This course provides in-depth education on EMS communication systems, professional radio practices, interpersonal communication, structured handoff techniques, and legally sound documentation. Participants will explore the essential components of the Prehospital Care Report (PCR), consent and refusal considerations, HIPAA responsibilities, and strategies for avoiding common communication failures.

Through real-world case studies, EMS providers will apply lessons learned to improve patient safety, professional credibility, and overall system performance.

Objectives

Upon completion of this course, the participant should be able to:

Explain the structure and function of modern EMS communication systems.
Identify best practices for radio communication with dispatch and medical direction.
Describe the legal and clinical importance of the Prehospital Care Report (PCR).
Identify required elements of complete and accurate EMS documentation.
Explain the processes of patient consent and informed refusal.

Curriculum

Chapter 1: EMS Communication Systems and Professional Interaction

The EMS Communication Continuum
The Evolution of EMS Communication Systems
Components of EMS Communication Equipment
Equipment Maintenance and Reliability
Professional Radio Etiquette
- Communication with Dispatch
- Communicating with Medical Direction
- The Critical Moment: Hospital Handoff
- Interpersonal Communication with Patients and Families

Chapter 2: Prehospital Documentation and the PCR

The True Role of Documentation in EMS
The PCR as a Legal Document
Required Elements of a Complete PCR
Writing an Effective Narrative
Common Documentation Errors
Electronic PCR Considerations
Patient Confidentiality and HIPAA
Documenting Consent and Refusal

Chapter 3: Case Studies

Case Study 1 – The “En Route” That Wasn’t
Case Study 2 – “I Thought You Called the Hospital”
Case Study 3 – Dangerous Dispatch Assumptions
Case Study 4 – The Missing Neurological Exam
Case Study 5 – The Questionable Refusal

Price: $12.00

Contact Hour: 1

Course Author

Brad Moore

Brad Moore is a dedicated public safety professional with over 18 years of service in emergency response. He has been a firefighter since 2021 and became a licensed paramedic in 2023, providing critical care in high-pressure situations. Before transitioning to Fire and EMS, Brad served for 12 years as a police officer, where he developed strong skills in leadership, crisis management, public safety, and community service. He is also a licensed EMS Instructor through the Texas Department of State Health Services, further extending his expertise in training and education for emergency responders.

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Course Accreditation

Provider approved by the Texas Department of State Health Services, course provides _____ contact hour(s). CE Program Approval Number #: 601011.