Ch 5 communicating w team
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Communicating in the healthcare team

Communicating in the healthcare team

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  • You need to understand the rules of communication.
  • A message sent is received and correctly interpreted by the intended person. If you do not know what a term means, ask the nurse. Use a medical dictionary. Do not use terms unfamiliar to the person and family. Avoid wandering in thought. Present your thoughts step-by-step. The receiver should have a clear picture of what you are saying.
  • The Omnibus Budget Reconciliation Act of 1987 (OBRA) calls the medical record the clinical record.
  • Some agencies allow nursing assistants to record observations and care. Others do not.
  • You have an ethical and legal duty to keep the person’s information confidential. Patients and residents have the right to the information in their medical records. If the person or the person’s legal representative asks you for the chart, report the request to the nurse. Use the admission sheet to fill out other forms that require the same information.
  • Review the Focus on Long-Term Care and Home Care: Progress Notes Box on p. 59 in the textbook. Review the Focus on Long-Term Care and Home Care: Flow Sheets Box on p. 61 in the textbook.
  • Review the Teamwork and Time Management: Reporting Box on p. 61 in the textbook.
  • End-of-shift report is given to the nursing team of the on-coming shift. In some agencies, the entire nursing team hears the end-of-shift report as they come on duty. In other agencies, only nurses hear the report. After the report, they share important information with nursing assistants. Review the Teamwork and Time Management: End-of-Shift Report Box on p. 63 in the textbook. Review the Promoting Safety and Comfort: End-of-Shift Report Box on p. 63 in the textbook.
  • Review the rules in Box 5-1 on p. 63 in the textbook. Review the Focus on Ethics and Laws: Recording Box on p. 64 in the textbook.
  • Refer to Box 5-2 on p. 64 in the textbook.
  • Obtain a list of your agency’s accepted abbreviations when you are hired. Refer to the inside of the back book cover for common abbreviations. Review the Common terms that apply to basic care and safety in Box 5-4 on p. 68 in the textbook.
  • The health team uses computers, PDAs, and faxes to send messages and reports to the nursing unit. Computers are used for measurements such as blood pressure, temperature, and heart rate. If allowed access, you will learn how to use the agency’s system. You must maintain the confidentiality of protected health information (PHI) and electronic protected health information (e PHI ; EPHI) . Review the rules in Box 5-5 on pp. 69-70 in the textbook.
  • You need to: Be professional and courteous. Practice good work ethics. Follow the agency’s policy. Follow the guidelines in Box 5-6 on p. 70 in the textbook. Review the Focus on Long-Term Care and Home Care: Phone Communications Box on p. 68 in the textbook.

Ch 5 communicating w team Ch 5 communicating w team Presentation Transcript

  • Chapter 5Communicating With the Health Team Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
  • Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 2
  • - Communicate to give coordinated & effective care.- share information about: • What was done • What needs to be done • Response to treatment Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 3
  • Activity-Divide into pairs- 1. Student 1 draw a picture on graph paper- 2. Student 1 will then give directions to student 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
  • 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 clarifying information lead to better patient care? Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 5
  • 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
  • Non verbal communicationMosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 7
  • Factors of ineffective communication Guilt/grief Emotions Unfamiliar words Culture Interrupting Giving opinions Excessive talking Saying “don’t worry Stress Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
  • Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 9
  • Answer call light Answer promptly Turn of when in room Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 10
  • THE MEDICAL RECORD-a written or electronic account of a pt’s 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
  • 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
  • Medical record -organized into sections -pgs. stamped with pt’s name, room, & medical record #Policies about medical records : • Who records • When to record • Abbreviations • Correcting errors • Ink color • Signature Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 14
  • Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 15
  • Policies r/t medical record -know agency’s policies-parts of the medical record r/t NA: • admission sheet • health history (nursing history) • graphic sheet • Progress notes • Flow sheets Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 16
  • Graphics sheetMosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 17
  • Flow sheetMosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 18
  • THE KARDEX- type of card file.-summarizes information- Quick reference- Not a permanent part of medical record THE KARDEX Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 19
  • Activity Review kardex and answer questions about pt. Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 20
  • 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 report Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 21
  • Progress NoteMosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 22
  • Report guidelines -Be prompt, thorough, & accurate. -Give the pt’s 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
  • When to report - as often as pt’s condition requires. -Report changes from normal or changes in the person’s 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
  • 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 pt’s condition Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 25
  • Anyone who reads your charting should know: What you observed What you did The pt’s response Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 26
  • Documentation rules Use ink  Don’t :erase, Neat -use white out Correct spelling -scribble Approved -skip lines abbreviations -Sign all entries Chart what you did/observe Describe Record safety measures taken Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 27
  • Demonstrate how to correctly fix a charting error Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 28
  • Recording time • Figure 5-8: The 24-hour clockMosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 29
  • 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 pm Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 30
  • Activity 2330 0425 1500 1135 1932 Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 31
  • 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
  • Medical Abbreviations Lesson: NPO -nothing by mouth Stat  immediately PO  By mouth ADL  Activities of daily living I&O  Intake and output Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 33
  •  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
  •  s  without q  every p  after HS  Hours of sleep pt  Patient see back cover – more abbreviations Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 35
  • 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
  • Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 37
  • Directional Terms give direction of the body part when pt. is standing & facing forward. • Anterior (ventral) • Distal • Lateral • Medial • Posterior (dorsal) • Proximal Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 38
  • Anatomical PositionMosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. 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
  • COMPUTERS & OTHER ELECTRONIC DEVICES Computer systems & personal digital assistants (PDAs) collect, send, record, & store information. • Improves speed & accuracy. Follow agency’s policies • Protect right to privacy & confidentiality Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 42
  • PHONE COMMUNICATIONS Good communication skills information interpreted by: • tone of voice • how clearly you speak • attitude Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 43
  • ActivityRole play phone conversations Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 44
  • ConflictsSteps to resolve: 1. define problem 2. collect information 3. select best solution 4. carry out solution 5.evaluate Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 45
  • Guidelines-give facts -set date to re--talk privately evaluate-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
  • 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