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.