UTSW/BioTel Policy: Radio/Telephone and In-Person Verbal Patient Reporting

Purpose:  The purpose of this policy is to set forth the minimum standards for the communication of vital patient information when giving radio or telephone report, and when providing this information in person at the receiving hospital.

1. POLICY:

EMS providers shall provide a succinct patient report by radio or telephone to BioTel or directly to the receiving hospital, as well as in-person once at a receiving facility, in accordance with the following standards.

2. FIELD COMMUNICATION – REPORT FORMAT:

1. Paramedics shall ALWAYS document the name of the BioTel staff member receiving report or the name of the receiving hospital and hospital staff member receiving report.
2. When contacting BioTel, paramedics shall communicate whether contact is for routine hospital notification, or for another reason, such as:
   1. Specialty Care Notification (Trauma, Burn, STEMI, Stroke, etc.);
   2. BioTel Consultation;
   3. BioTel Medical Command (physician) Consultation;
   4. Termination of Resuscitation (Field Termination Pronouncement);
   5. Destination Decision-making;
   6. AMA/Patient Refusal;
   7. Other.
3. Paramedics’ field report to either BioTel or directly to a receiving hospital shall include at a minimum:
   1. EMS agency and unit number;
   2. Age and gender;
   3. Chief complaint/or mechanism of injury;
   4. Vital signs;
   5. Level of consciousness;
   6. Transport code and ETA;
   7. Whether the patient has had a supraglottic or endotracheal airway in place;
   8. Any other pertinent patient information.

3. RECEIVING HOSPITAL COMMUNICATION – REPORT FORMAT:
   1. Paramedics shall ALWAYS document the name of the hospital staff member receiving report both by radio/telephone and in person.
   2. For critical or “Specialty Care” patients, upon entering a room with multiple staff members present, ask “Who will be taking report today?” and then direct your comments to that staff member.
   3. The in-hospital verbal report shall include at a minimum:
      1. Age and gender;
      2. Chief complaint/or mechanism of injury;
      3. Vital signs;
      4. Level of consciousness;
      5. Pertinent positive and negative physical findings;
      6. Any interventions performed and the patient’s response to those interventions;
      7. Any medications given, including the dose, route and response to the medication;
      8. Any additional information that the treatment team might need to effectively care for that patient.
4. VERBAL REPORT FOR CRITICAL PEDIATRIC PATIENTS UPON ARRIVAL AT CHILDREN’S MEDICAL CENTER:
   1. Upon arrival at CMC with a critical pediatric patient, CMC staff will FIRST perform a primary survey of your patient BEFORE receiving report.
   2. Once CMC personnel have completed the primary survey AND any necessary critical interventions, paramedics will then be asked to give report. 
   3. With this in mind, providing a complete verbal report by radio or telephone to BioTel regarding the transport of a critical pediatric patient to CMC is both critical and mandatory.
5. RADIO OR TELEPHONE COMMUNICATION FAILURE OR INABILITY OF PARAMEDICS TO GIVE REPORT:

In the event of radio or telephone communication failure in the field or if paramedics are too busy attending to a critically ill patient to give report, they shall request that their respective dispatch center relay as much patient information as possible to BioTel as early in the transport as possible.

6. QUALITY IMPROVEMENT:
   BioTel will work with our EMS Agency and receiving hospital partners to monitor, report, and improve the quality of field-to-hospital and in-hospital patient verbal reporting.