Page 46 - ATP-P 11th Ed

Communication and Documentation

SECTION 1 Background
Communication and documentation in PCC are linked priorities as they are activities that
are synergistic. For instance, the standard documentation forms (see below) that are used
to track the important medical interventions and trends are the recommended scripts that
are used in a teleconsultation. Effective documentation leads to effective communication,
both in the immediate PCC environment and as a long-term medical management tool for
the casualty.
Communication
a. Communicate with the casualty if possible. Encourage, reassure, and explain care.
b. Communicate with tactical leadership as soon as possible and throughout casualty treat-
ment as needed. Provide leadership with casualty status and evacuation requirements to
assist with coordination of evacuation assets.
c. Verify evacuation request has been transmitted and establish communication with the
evacuation platform as soon as tactically feasible relaying: mechanism of injury, injuries
sustained, signs/symptoms, treatments rendered, and other information as appropriate.
Have a rehearsed script to relay vital information to the next echelon of care prioritize
interventions that cannot be seen by the next provider, such as medications.
d. Ensure appropriate notification up the chain of command that PCC is being conducted;
requesting support based on the MASCAL decision points.
e. Call for teleconsultation as early and as often as needed (e.g., higher medical capability
in the Chain of Command, the Advanced Virtual Support for Operational Forces system
line, etc.).
f. Remember, communication of the situation and medical interventions that have been
done and are ongoing includes both teleconsultation and the “handoff report.”
Documentation of Care
a. There are 3 levels of documentation, categorized in a minimum, better, best format:
i. Minimum: Documentation of care on the TCCC card (DD1380).
ii. Better: Utilization of a standard PCC flowsheet (if available), example attached.
iii. Best: Completion of a formal After Action Report (AAR) after patient handoff.
b. Transfer documented clinical assessments and treatments rendered. If the availably to
scan and/or transmit this information to all parties involved teleconsultation (using all
approved and available means), do so for them to have as much of the information as
possible.
c. Perform a detailed head-to-toe assessment and record all findings as a problem list so
that a comprehensive care plan can then be constructed using the attached flow sheet.

36 SECTION 1 TACTICAL TRAUMA PROTOCOLS (TTPs) ATP-P Handbook 11th Edition 37