- 1. Chapter 5Communicating With theHealth Team Mosby items and
derived items 2008 by Mosby, Inc., an affiliate of Elsevier
Inc.
2. Mosby items and derived items 2008 by Mosby, Inc., an
affiliate of Elsevier Inc. Slide 2 3. - Communicate to give
coordinated & effectivecare.- share information about: What was
done What needs to be done Response to treatmentMosby items and
derived items 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 3 4. Activity-Divide into pairs- 1. Student 1 draw a picture
on graph paper- 2. Student 1 will then give directions tostudent
2,- 3. Student 2 will attempt to draw picture 4. After student 1
has completed giving directions, compare picturesSwitch roles Mosby
items and derived items 2008 by Mosby, Inc., an affiliate of
Elsevier Inc. Slide 4 5. Think about it Which drawing was more
accurate? Why is the second drawing more accurate? Put this
situation into a healthcare context How can asking questions and
clarifyinginformation lead to better patient care? Mosby items and
derived items 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 5 6. COMMUNICATION Communication is the exchange of
information-good communication: Use words that mean the same to you
& resident Use familiar words. Be brief & concise. Give
information in logical & orderly manner. Give facts Be
specific.Mosby items and derived items 2008 by Mosby, Inc., an
affiliate of Elsevier Inc. Slide 6 7. Non verbal communicationMosby
items and derived items 2008 by Mosby, Inc., an affiliate of
Elsevier Inc. Slide 7 8. Factors of ineffectivecommunication
Guilt/grief Emotions Unfamiliar words Culture Interrupting Giving
opinions Excessive talking Saying dont worry Stress Mosby items and
derived items 2008 by Mosby, Inc., an affiliate of Elsevier Inc. 9.
Mosby items and derived items 2008 by Mosby, Inc., an affiliate of
Elsevier Inc. Slide 9 10. Answer call light Answer promptly Turn of
when in roomMosby items and derived items 2008 by Mosby, Inc., an
affiliate of Elsevier Inc. Slide 10 11. THE MEDICAL RECORD-a
written or electronic account of a pts condition &response to
treatment and care.-a permanent, legal document.-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 11 12. Mosby items
and derived items 2008 by Mosby, Inc., an affiliate of Elsevier
Inc. Slide 12 13. Mosby items and derived items 2008 by Mosby,
Inc., an affiliate of Elsevier Inc. Slide 13 14. Medical record
-organized into sections -pgs. stamped with pts name, room, &
medical record #Policies about medical records : Who records When
to record Abbreviations Correcting errors Ink color SignatureMosby
items and derived items 2008 by Mosby, Inc., an affiliate of
Elsevier Inc. Slide 14 15. Mosby items and derived items 2008 by
Mosby, Inc., an affiliate of Elsevier Inc. Slide 15 16. Policies
r/t medical record -know agencys policies-parts of the medical
record r/t NA: admission sheet health history (nursing
history)graphic sheetProgress notesFlow sheets Mosby items and
derived items 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 16 17. Graphics sheetMosby items and derived items 2008 by
Mosby, Inc., an affiliate of Elsevier Inc. Slide 17 18. Flow
sheetMosby items and derived items 2008 by Mosby, Inc., an
affiliate of Elsevier Inc. Slide 18 19. THE KARDEX- type of card
file.-summarizes information-Quick reference-Not a permanent part
of medical recordTHE KARDEXMosby items and derived items 2008 by
Mosby, Inc., an affiliate of Elsevier Inc. Slide 19 20. Activity
Review kardex and answer questions aboutpt.Mosby items and derived
items 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 20
21. REPORTING & RECORDING -Report tell about pt. to next
shift.-Record (charting) - written account of care
&observations.Report to the nurse:-Whenever there is a change
in condition-When the nurse asks you to-Before the end-of-shift
reportMosby items and derived items 2008 by Mosby, Inc., an
affiliate of Elsevier Inc. Slide 21 22. Progress NoteMosby items
and derived items 2008 by Mosby, Inc., an affiliate of Elsevier
Inc. Slide 22 23. Report guidelines -Be prompt, thorough, &
accurate. -Give the pts name. -Report only what you observed or did
yourself.Mosby items and derived items 2008 by Mosby, Inc., an
affiliate of Elsevier Inc. Slide 23 24. When to report - as often
as pts condition requires. -Report changes from normal or changes
in the persons condition at once -Use notes to give a specific,
concise, & clear report.Mosby items and derived items 2008 by
Mosby, Inc., an affiliate of Elsevier Inc. Slide 24 25.
End-of-shift report (change-of-shift report) Provide the following
:-care given-care that must be given during next shift-current
condition-Likely changes in pts conditionMosby items and derived
items 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 25
26. Anyone who reads your charting should know: What you observed
What you did The pts response Mosby items and derived items 2008 by
Mosby, Inc., an affiliate of Elsevier Inc. Slide 26 27.
Documentation rules Use ink Dont :erase, Neat-use white out Correct
spelling-scribble Approved-skip linesabbreviations-Sign all entries
Chart what youdid/observe Describe Record safetymeasures taken
Mosby items and derived items 2008 by Mosby, Inc., an affiliate of
Elsevier Inc. Slide 27 28. Demonstrate how to correctly fixa
charting errorMosby items and derived items 2008 by Mosby, Inc., an
affiliate of Elsevier Inc. Slide 28 29. Recording time Figure 5-8:
The 24-hour clockMosby items and derived items 2008 by Mosby, Inc.,
an affiliate of Elsevier Inc. Slide 29 30. Activity Convert time
using the 24-hour clock: 2:05 am 3:15 am 1:06 pm 12:10 pm 6:35 am
10:36 pmMosby items and derived items 2008 by Mosby, Inc., an
affiliate of Elsevier Inc. Slide 30 31. Activity 2330 0425 1500
1135 1932Mosby items and derived items 2008 by Mosby, Inc., an
affiliate of Elsevier Inc. Slide 31 32. Medical abbreviations
-Abbreviations are shortened forms of words or phrases. -agency has
list of accepted medical abbreviations.Mosby items and derived
items 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 32
33. Medical Abbreviations Lesson: NPO-nothing by mouth Stat
immediately PO By mouth ADL Activities of daily living I&O
Intake and outputMosby items and derived items 2008 by Mosby, Inc.,
an affiliate of Elsevier Inc. Slide 33 34. TPR Temperature, pulse,
respiration qd Every day PRN As needed c with Mosby items and
derived items 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 34 35. swithout qevery pafter HSHours of sleep ptPatientsee
back cover more abbreviations Mosby items and derived items 2008 by
Mosby, Inc., an affiliate of Elsevier Inc. Slide 35 36. Abdominal
Regions - used to describe the location of body structures, pain,
or discomfort. The regions are:Right upper quadrant (RUQ)Left upper
quadrant (LUQ)Right lower quadrant (RLQ)Left lower quadrant
(LLQ)Mosby items and derived items 2008 by Mosby, Inc., an
affiliate of Elsevier Inc. Slide 36 37. Mosby items and derived
items 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 37
38. Directional Termsgive direction of the body part when pt.
isstanding & facing forward. Anterior (ventral) Distal Lateral
Medial Posterior (dorsal) ProximalMosby items and derived items
2008 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 38 39.
Anatomical PositionMosby items and derived items 2008 by Mosby,
Inc., an affiliate of Elsevier Inc. Slide 39 40. Mosby items and
derived items 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 40 41. Mosby items and derived items 2008 by Mosby, Inc., an
affiliate of Elsevier Inc. Slide 41 42. COMPUTERS &
OTHERELECTRONIC DEVICESComputer systems & personal digital
assistants (PDAs) collect, send, record, & store information.
Improves speed & accuracy.Follow agencys policies Protect right
to privacy & confidentialityMosby items and derived items 2008
by Mosby, Inc., an affiliate of Elsevier Inc. Slide 42 43. PHONE
COMMUNICATIONSGood communication skillsinformation interpreted by:
tone of voice how clearly you speak attitudeMosby items and derived
items 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 43
44. ActivityRole play phone conversationsMosby items and derived
items 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 44
45. ConflictsSteps to resolve:1. define problem2. collect
information3. select best solution4. carry out solution5.evaluate
Mosby items and derived items 2008 by Mosby, Inc., an affiliate of
Elsevier Inc. Slide 45 46. Guidelines-give facts-set date to
re--talk privatelyevaluate-polite & professional -thank
person-explain problem & your feelings-listen-do not
interrupt-offer idea to solve issue-Ask their ideas items 2008 by
Mosby, Inc., an affiliate of Elsevier Inc.Mosby items and derived
Slide 46 47. activityRole play the conflict situations you have
been given Mosby items and derived items 2008 by Mosby, Inc., an
affiliate of Elsevier Inc. Slide 47
