OEC CH08: Patient Communication & Documentation

26/06/2025 17 min

Listen "OEC CH08: Patient Communication & Documentation"

Episode Synopsis

This chapter from Outdoor Emergency Care: A Patroller's Guide to Medical Care (6th edition)  focuses on the critical importance of effective communication and detailed documentation for Outdoor Emergency Care (OEC) technicians. It outlines various resources available for both instructors and students, emphasizing the need for OEC technicians to proficiently use oral communication, including specific techniques like the SAILER acronym for dispatch reports and concise handoff reports for other medical personnel, and written documentation, such as field care notes, incident report forms, and comprehensive patient care reports (PCRs). The text highlights that all medical communication must adhere to patient privacy rules and be factual, accurate, complete, unbiased, and error-free to serve both medical treatment and legal purposes. Ultimately, the goal is to create a clear and consistent "clinical picture" of the patient's condition and care, ensuring seamless transitions of care and thorough record-keeping.