COMMUNICATIONCOMMUNICATION

PURPOSES OF CLIENT PURPOSES OF CLIENT RECORDSRECORDS

• 1. Communication1. Communication• 2. Planning client care2. Planning client care• 3. Auditing3. Auditing• 4. Research 4. Research • 5. Education5. Education• 6. Reimbursement6. Reimbursement• 7. Legal Documentation7. Legal Documentation• 8. Health care analysis8. Health care analysis

DOCUMENTATION DOCUMENTATION SYSTEMSSYSTEMS

1. Source-oriented1. Source-oriented 2. Problem-Oriented Medical Record2. Problem-Oriented Medical Record 3. Focus Charting3. Focus Charting 4. Charting by Exception4. Charting by Exception 5. FACT5. FACT 6. CORE6. CORE 7. Outcome Documentation 7. Outcome Documentation 8. Computerized 9. Case management8. Computerized 9. Case management

Legal Issues related to Legal Issues related to written documentationwritten documentation

DOCUMENTING NSG DOCUMENTING NSG ACTIVITIESACTIVITIES

1. Admission Nsg Assessment1. Admission Nsg Assessment 2. Flow sheets (4 types +)2. Flow sheets (4 types +) 3. Nsg care plan, Kardex, critical 3. Nsg care plan, Kardex, critical

pathway, progress notes, problem pathway, progress notes, problem listlist

4. Nsg discharge/Referral 4. Nsg discharge/Referral SummariesSummaries

CHANGE OF SHIFT REPORTCHANGE OF SHIFT REPORTTYPES (2)TYPES (2)

1. Focused report1. Focused report 2. Walking rounds 2. Walking rounds

SHIFT REPORT DATASHIFT REPORT DATA

SEE deWitt page 30 -table 2-5SEE deWitt page 30 -table 2-5 SEE KOZIER page 361 SEE KOZIER page 361

TELEPHONE REPORTSTELEPHONE REPORTS

1. Repeat information to caller1. Repeat information to caller 2. Document date and time2. Document date and time 3. Document name of person 3. Document name of person

giving informationgiving information 4. Document information received4. Document information received 5. Sign notation5. Sign notation

TELEPHONE ORDERSTELEPHONE ORDERS

1. Identify caller1. Identify caller 2. Repeat info to caller2. Repeat info to caller 3. Transcribe order and indicate 3. Transcribe order and indicate

TOTO

Long-term Care Long-term Care DocumentationDocumentation

SEE Kozier page 356SEE Kozier page 356

HOME CARE HOME CARE DOCUMENTATIONDOCUMENTATION

SEE KOZIER 356SEE KOZIER 356

GUIDELINES FOR GUIDELINES FOR RECORDINGRECORDING

1. Date and time1. Date and time 2. Timing2. Timing 3. Legibility 3. Legibility 4. Permanence4. Permanence 5. Accepted terminology5. Accepted terminology 6. Correct spelling6. Correct spelling 7. Signature 8. Accuracy 9. 7. Signature 8. Accuracy 9.

SequenceSequence

(Con’t)(Con’t)

10. Appropriateness10. Appropriateness 11. Completeness11. Completeness 12. Conciseness12. Conciseness 13. Legal prudence13. Legal prudence

COMMUNICATION COMMUNICATION TECHNIQUESTECHNIQUES

1. Communication process1. Communication process 2. Modes of communication2. Modes of communication 3. Factors influencing 3. Factors influencing

communication processcommunication process 4. Therapeutic communication4. Therapeutic communication 5. Barriers to communication5. Barriers to communication 6. Nsg process & communication6. Nsg process & communication