Download ppt - Ch 5 communicating w team

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


- 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


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

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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?

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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.


Non verbal communicationNon verbal communication

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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

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Answer call lightAnswer call light

Answer promptlyAnswer promptly Turn of when in roomTurn of when in room

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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.




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



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


Graphics sheetGraphics sheet

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Flow sheetFlow sheet

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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


ActivityActivity

Review kardex and answer questions about Review kardex and answer questions about pt.pt.

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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


Progress NoteProgress Note

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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.


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.


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


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


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

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Demonstrate how to correctly fix Demonstrate how to correctly fix a charting errora charting error

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Recording timeRecording time

• Figure 5-8: The 24-hour clock Figure 5-8: The 24-hour clock


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

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ActivityActivity

23302330 04250425 15001500 11351135 19321932

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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.


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

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TPRTPR Temperature, pulse, respirationTemperature, pulse, respiration

qdqd Every dayEvery day

PRNPRN As neededAs needed

cc withwith

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ss withoutwithout

qq everyevery

pp afterafter

HSHS Hours of sleepHours of sleep

ptpt PatientPatient see back cover – more abbreviations see back cover – more abbreviations

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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)



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

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Anatomical PositionAnatomical Position

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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


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


ActivityActivity

Role play phone conversationsRole play phone conversations

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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

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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

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activityactivity

Role play the conflict situations you have been Role play the conflict situations you have been givengiven

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