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Communicating in the healthcare team
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Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
Chapter 5Chapter 5
Communicating With the Communicating With the Health TeamHealth Team
Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 2
Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 3
- Communicate to give coordinated & effective Communicate to give coordinated & effective care.care.
- share information about:share information about:• What was done What was done
• What needs to be done What needs to be done
• Response to treatmentResponse to treatment
Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
ActivityActivity
--Divide into pairsDivide into pairs- 1. Student 1 draw a picture on graph paper1. Student 1 draw a picture on graph paper- 2. Student 1 will then give directions to 2. Student 1 will then give directions to student student
2, 2, - 3. Student 2 will attempt to draw picture3. Student 2 will attempt to draw picture
4. After student 1 has completed giving 4. After student 1 has completed giving directions, compare picturesdirections, compare pictures
Switch rolesSwitch roles
Slide 4
Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
Think about itThink about it
Which drawing was more accurate?Which drawing was more accurate? Why is the second drawing more accurate?Why is the second drawing more accurate? Put this situation into a healthcare contextPut this situation into a healthcare context How can asking questions and clarifying How can asking questions and clarifying
information lead to better patient care?information lead to better patient care?
Slide 5
Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 6
COMMUNICATIONCOMMUNICATIONCommunication is the exchange of informationCommunication is the exchange of information
-good communication:-good communication:• Use words that mean the same to you & resident Use words that mean the same to you & resident
• Use familiar words.Use familiar words.
• Be brief & concise.Be brief & concise.
• Give information in logical & orderly manner.Give information in logical & orderly manner.
• Give facts Give facts
• Be specific.Be specific.
Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
Non verbal communicationNon verbal communication
Slide 7
Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
Factors of ineffective Factors of ineffective communicationcommunication
Guilt/griefGuilt/grief EmotionsEmotions Unfamiliar wordsUnfamiliar words CultureCulture InterruptingInterrupting Giving opinionsGiving opinions Excessive talkingExcessive talking Saying “don’t worrySaying “don’t worry StressStress
Slide 8
Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 9
Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
Answer call lightAnswer call light
Answer promptlyAnswer promptly Turn of when in roomTurn of when in room
Slide 10
Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 11
THE MEDICAL RECORDTHE MEDICAL RECORD
-a written or electronic account of a pt’s condition & -a written or electronic account of a pt’s condition & response to treatment and care.response to treatment and care.
-a permanent, legal document.-a permanent, legal document.
-It can be used as evidence in a court of law.-It can be used as evidence in a court of law.
Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 12
Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 13
Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 14
Medical recordMedical record
-organized into sections -organized into sections -pgs. stamped with pt’s name, room, & medical record # -pgs. stamped with pt’s name, room, & medical record #
Policies about medical records :Policies about medical records :• Who recordsWho records• When to recordWhen to record• AbbreviationsAbbreviations• Correcting errorsCorrecting errors• Ink colorInk color• SignatureSignature
Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 15
Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 16
Policies r/t medical recordPolicies r/t medical record
-know agency’s policies -know agency’s policies
-parts of the medical record r/t NA:-parts of the medical record r/t NA:• admission sheet admission sheet
• health history (nursing history) health history (nursing history) • graphic sheet graphic sheet
• Progress notes Progress notes
• Flow sheets Flow sheets
Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
Graphics sheetGraphics sheet
Slide 17
Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
Flow sheetFlow sheet
Slide 18
Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 19
THE KARDEXTHE KARDEX
- type of card file. - type of card file.
-summarizes information -summarizes information - Quick referenceQuick reference- Not a permanent part of medical recordNot a permanent part of medical record
THE KARDEX
Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
ActivityActivity
Review kardex and answer questions about Review kardex and answer questions about pt.pt.
Slide 20
Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 21
REPORTING & RECORDING REPORTING & RECORDING
--Report –tell about pt. to next shift.Report –tell about pt. to next shift.-Record (charting) - written account of care & -Record (charting) - written account of care &
observations. observations. Report to the nurse:Report to the nurse:
-Whenever there is a change in condition-Whenever there is a change in condition-When the nurse asks you to -When the nurse asks you to -Before the end-of-shift report-Before the end-of-shift report
Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
Progress NoteProgress Note
Slide 22
Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 23
Report guidelinesReport guidelines
-Be prompt, thorough, & accurate.-Be prompt, thorough, & accurate.
-Give the pt’s name.-Give the pt’s name.
-Report only what you observed or did yourself.-Report only what you observed or did yourself.
Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 24
When to reportWhen to report
- as often as pt’s condition requires.- as often as pt’s condition requires.
-Report changes from normal or changes in the person’s -Report changes from normal or changes in the person’s condition at oncecondition at once
-Use notes to give a specific, concise, & clear report.-Use notes to give a specific, concise, & clear report.
Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 25
End-of-shift report (change-of-shift report)End-of-shift report (change-of-shift report)
Provide the following :Provide the following :-care given -care given
-care that must be given during next shift-care that must be given during next shift
-current condition-current condition
-Likely changes in pt’s condition-Likely changes in pt’s condition
Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 26
Anyone who reads your charting should know:Anyone who reads your charting should know:
What you observedWhat you observed
What you didWhat you did
The pt’s responseThe pt’s response
Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
Documentation rulesDocumentation rules
Use inkUse ink NeatNeat Correct spellingCorrect spelling Approved Approved
abbreviationsabbreviations Chart what you Chart what you
did/observedid/observe DescribeDescribe Record safety Record safety
measures takenmeasures taken
Don’t :erase, Don’t :erase,
-use white out-use white out
-scribble -scribble
-skip lines-skip lines
-Sign all entries-Sign all entries
Slide 27
Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
Demonstrate how to correctly fix Demonstrate how to correctly fix a charting errora charting error
Slide 28
Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 29
Recording timeRecording time
• Figure 5-8: The 24-hour clock Figure 5-8: The 24-hour clock
Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
ActivityActivity
Convert time using the 24-hour clock:Convert time using the 24-hour clock: 2:05 am2:05 am 3:15 am3:15 am 1:06 pm1:06 pm 12:10 pm12:10 pm 6:35 am6:35 am 10:36 pm10:36 pm
Slide 30
Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
ActivityActivity
23302330 04250425 15001500 11351135 19321932
Slide 31
Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 32
Medical abbreviationsMedical abbreviations
--Abbreviations are shortened forms Abbreviations are shortened forms of words or phrases.of words or phrases.
-agency has list of accepted medical -agency has list of accepted medical abbreviations.abbreviations.
Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
Medical Abbreviations Lesson:Medical Abbreviations Lesson:
NPONPO-nothing by mouth-nothing by mouth
StatStat immediatelyimmediately
POPO By mouthBy mouth
ADLADL Activities of daily livingActivities of daily living
I & OI & O Intake and outputIntake and output
Slide 33
Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
TPRTPR Temperature, pulse, respirationTemperature, pulse, respiration
qdqd Every dayEvery day
PRNPRN As neededAs needed
cc withwith
Slide 34
Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
ss withoutwithout
qq everyevery
pp afterafter
HSHS Hours of sleepHours of sleep
ptpt PatientPatient see back cover – more abbreviations see back cover – more abbreviations
Slide 35
Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 36
Abdominal RegionsAbdominal Regions
- used to describe the location of body structures, pain, or - used to describe the location of body structures, pain, or discomfort.discomfort.
• The regions are:The regions are: Right upper quadrant (RUQ)Right upper quadrant (RUQ) Left upper quadrant (LUQ)Left upper quadrant (LUQ) Right lower quadrant (RLQ)Right lower quadrant (RLQ) Left lower quadrant (LLQ)Left lower quadrant (LLQ)
Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 37
Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
Directional TermsDirectional Terms
give direction of the body part when pt. is give direction of the body part when pt. is standing & facing forward.standing & facing forward.
• Anterior (ventral)Anterior (ventral)• DistalDistal• LateralLateral• MedialMedial• Posterior (dorsal)Posterior (dorsal)• ProximalProximal
Slide 38
Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
Anatomical PositionAnatomical Position
Slide 39
Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 40
Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 41
Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 42
COMPUTERS & OTHER COMPUTERS & OTHER ELECTRONIC DEVICESELECTRONIC DEVICES
Computer systems & personal digital assistants Computer systems & personal digital assistants (PDAs) collect, send, record, & store (PDAs) collect, send, record, & store information.information.
• Improves speed & accuracy.Improves speed & accuracy.
Follow agency’s policies Follow agency’s policies • Protect right to privacy & confidentialityProtect right to privacy & confidentiality
Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 43
PHONE COMMUNICATIONSPHONE COMMUNICATIONS
Good communication skills Good communication skills information interpreted by:information interpreted by:
• tone of voicetone of voice
• how clearly you speakhow clearly you speak
• attitudeattitude
Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
ActivityActivity
Role play phone conversationsRole play phone conversations
Slide 44
Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
ConflictsConflicts
Steps to resolve:Steps to resolve:
1. define problem1. define problem
2. collect information2. collect information
3. select best solution3. select best solution
4. carry out solution4. carry out solution
5.evaluate5.evaluate
Slide 45
Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
GuidelinesGuidelines
-give facts-give facts
-talk privately-talk privately
-polite & professional-polite & professional
-explain problem & your -explain problem & your feelingsfeelings
-listen-listen
-do not interrupt-do not interrupt
-offer idea to solve issue-offer idea to solve issue
-Ask their ideas-Ask their ideas
-set date to re--set date to re-evaluateevaluate
-thank person-thank person
Slide 46
Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
activityactivity
Role play the conflict situations you have been Role play the conflict situations you have been givengiven
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