Nursing Communication & Documentation

1. B Y :
M U H A M M A D B A Q A R
RN, BSN, MSPH
COMMUNICATION

2. COMMUNICATION
 Communication is the process people use to
exchange information through verbal and nonverbal
messages.
 Communication is the giving and receiving of
information.
 Sharing or transmitting thoughts or feelings

3. COMMUNICATION LEVELS
 Intrapersonal Communication
 Interpersonal Communication
 Group Communication
 Public Speaking

4. COMMUNICATION COMPONENTS
 Content
 Process

5. COMMUNICATION COMPONENTS
Content
 The content of communication describes the actual
subject matter, words, gestures, and substance of the
message. It is the message that everyone may hear or
see.
Process
 Process refers to the act of sending, receiving,
interpreting, and reacting to a message.

6. COMMUNICATION PROCESS

7. BASIC 5 FIVE ELEMENTS OF THE
COMMUNICATION PROCESS
Communication
Process
Feedback
Sender
Messages
The channel
Receiver

8. SENDER
 Begins the conversation to deliver a message
(content) to another person.
 The sender, also called the source or the encoder,
uses verbal and nonverbal methods to transmit the
message.
• Encoding: Refers to the process of selecting the
words, gestures, tone of voice, signs, and symbols
used to transmit the message.

9. MESSAGE
 Is the verbal and/or nonverbal information the
sender communicates.
 It might be content of a :
• Conversation
• Speech
• Gesture
• Letter, and
• So forth

10. EFFECTIVE MESSAGES
 Complete
 Clear
 Concise
 Organized
 timely, and
 Expressed in a manner that the receiver can
understand.

11. THE CHANNEL
 Is the medium used to send the message.
Examples:
• Face-to-face communication is a commonly used
channel.
• Nurses frequently use touch as a nonverbal way to
communicate caring and concern

12. THE CHANNEL
 Other channels include:
• Written pamphlets
• Audiovisual aids
• Recordings
• Telephone
• Text messages, and
• The Internet

13. RECEIVER:
 Is the person who receives the decodes the message.
 The receiver is the observer, listener, and interpreter of
the message.
 Interpretation, also called decoding:
 The receiver uses to decode the message
• Visual
• Auditory, and
• Tactile senses

14. FEEDBACK
 Is the message returned by the receiver. It indicates
whether the meaning of the sender’s message was
understood.

15. FORMS OF COMMUNICATION
 Verbal Communication
 Nonverbal Communication

16. VERBAL COMMUNICATION
 Is the use of spoken and written words to send a
message.
 Examples: Speaking, Listening, Writing, Reading.
 Occurs on a more Conscious level
 Verbal message goal is that the receiver will
understand both sender words and sender meaning

17. CHARACTERISTICS OF THE EFFECTIVE
VERBAL COMMUNICATION
 Pace and intonation: The manner of speech, rate or
rhythm and tone
 Simplicity: commonly understood words, shortness,
and completeness
 Clarity and brevity: simple and clear.
 Timing and relevance: Asking question . Appropriate ,
ensure words are heard. encourage the client to express
concerns, and then to deal with those concerns.

18. CHARACTERISTICS OF THE EFFECTIVE
VERBAL COMMUNICATION
 Adaptability: Adjust spoken messages with
behavioral cues from the client
 Modify client tone of speech and express concern by
facial expression while moving toward the client.
 Credibility: worthiness of belief, trustworthiness,
reliability and sincerity
 Humor: The physical act of laughter can be an
emotional and physical release.

19. NONVERBAL COMMUNICATION
(or body language)
 Is the exchange of messages without the use of
words.
 Occurs on a more unconscious level.
 Non-verbal communication is sometimes considered
a more accurate description of true feelings because
one has less control over non-verbal

20. NONVERBAL COMMUNICATION
(or body language)
Examples:
 Gestures
 Facial Expressions
 Posture and Gait
 Tone of Voice
 Touch
 Eye Contact
 Body Position
 Physical Appearance

21. FUNCTIONS OF COMMUNICATION
 Information
 Education
 Motivation
 point of view
 Counseling
 Rising morals
 Health development
 Organization
 Enhance productivity
 Conflict resolution

22. FACTORS AFFECT COMMUNICATION
 Environment
 Developmental
Variations
 Gender
 Values and Perceptions
 Territoriality
 Sociocultural Factors
 Roles and Relationships
 Judgment
 Personal Space
o Intimate: Touching(0) to
18 inches
o Personal: 18 Inches to 4
feet
o Social: 4 to 12 feet
o Public: 12 to 15 feet

24. THERAPEUTIC COMMUNICATION
 An interaction between a health care professional
and a patient that aims to enhance the patient's
comfort, safety, trust, or health and well-being.
 Sometimes called effective communication, it is
purposeful and goal-oriented, creating a beneficial
outcome for the client

25. GOALS OF
THERAPEUTIC COMMUNICATION
 To obtain or provide information
 To develop trust
 To show caring
 To explore feelings

26. THERAPEUTIC COMMUNICATION
TECHNIQUES
 Therapeutic communication techniques are specific
responses that encourage the expression of feelings
and ideas and convey acceptance and respect.

27. THERAPEUTIC COMMUNICATION
TECHNIQUES
 Active Listening
 Sharing Observations
 Sharing Empathy
 Sharing Hope
 Sharing Humor
 Sharing Feelings
 Using Touch.
 Using Silence
 Providing Information
 Clarifying.
 Focusing.
 Paraphrasing.
 Asking Relevant
Questions
 Summarizing
 Concreteness and
Confrontation.

28. NON THERAPEUTIC COMMUNICATION
TECHNIQUES
 Asking Personal
Questions
 Giving Personal
Opinions.
 Changing the Subject
 False Reassurance
 Sympathy
 Asking for Explanations
 Ask Approval or
Disapproval
 Defensive Responses
 Passive or Aggressive
Responses
 Arguing

29. COMMUNICATION SKILLS
 Know yourself
 Be honest with your
feelings
 Be sure in your ability to
relate to people
 Be sensitive to needs of
others
 Be reliable
 Recognize symptoms of
anxiety
 Watch your non-verbal
reactions
 Use words carefully
 Recognize differences
 Recognize and evaluate
your own actions and
responses.

30. COMMUNICATING WITH CARE
 Keep your attention in the moment and on the patient.
 While the patient is sharing personal information, tune in
and do not multitask.
 Maintain eye contact while listening.
 Do not interrupt the patient.
 Avoid looking at your cell phone or watch.
 Never text while the patient is talking.
 Do not casually talk with coworkers while the patient is
waiting.

31. PSYCHOSOCIAL ASPECTS OF
COMMUNICATION
 Style.
 Gestures.
 Meaning of time.
 Meaning of space.
 Cultural values.
 Political correctness

32. NURSE CLIENT COMMUNICATION
 Almost every nurse-client interaction should involve
therapeutic communication.
 Nurse-client communication is influenced by both
the nurse and the client.

33. THE THERAPEUTIC RELATIONSHIP
 The therapeutic relationship consists of four phases:
 Pre-interaction Phase
 Orientation Phase
 Working Phase
 Termination Phase

34. PRE-INTERACTION PHASE
Before meeting a patient:
 Review available data, including the medical and nursing history.
 Talk to other caregivers who have information about the patient.
 Anticipate health concerns or issues that arise.
 Identify a location and setting that fosters comfortable, private
interaction.
 Plan enough time for the initial interaction.

35. ORIENTATION PHASE/
INTRODUCTION
When the nurse and patient meet and get to know one another:
 Set the tone for the relationship by adopting a warm,
empathetic, caring manner.
 Recognize that the initial relationship is often superficial,
uncertain, and tentative.
 Expect the patient to test your competence and commitment.
 Closely observe the patient and expect to be closely observed
by the patient.

36. ORIENTATION PHASE/ INTRODUCTION
 Assess the patient’s health status.
 Clarify the patient’s and your roles.
 Form contracts with the patient that specify who will
do what.
 Let the patient know when to expect the relationship
to be terminated.

37. WORKING PHASE
 The active part of the relationship
 The nurse communicates caring
 The patient expresses thoughts and feelings
 Mutual respect is maintained
 Honest verbal and nonverbal expression occurs
 Key communication goals are
o To assist the client to clarify feelings and concerns

38. TERMINATION PHASE
During the ending of the relationship
 Remind the patient that termination is near.
 Evaluate goal achievement with the patient.
 Talk about the relationship with the patient.
 Separate from the patient by relinquishing responsibility for his
or her care.
 Achieve a smooth change for the patient to other caregivers as
needed.

39. THERAPEUTIC COMMUNICATION
ELEMENTS
 Trust and honesty: Avoid giving false
reassurances
 Empathy :Show a sense of understanding and
acceptance of the patient’s situation.
 Respect and courtesy: Use titles and names that
are acceptable to the patient.
 Encourage active participation in the decision-
making process.
 Privacy and confidentiality : Use during both the
interaction and away from the interaction.

40. BARRIERS TO
THERAPEUTIC INTERACTION
 Language Differences
 Cultural Differences
 Gender
 Developmental Level
 Health Status
 Knowledge Differences
 Emotional Distance
 Emotions
 Daydreaming

41. DETERMINANT FACTORS IN
COMMUNICATION
A nurse’s communication is affected by:
 Past Experience
 State of Health
 Home Situation
 Workload
 Staff Relations
 Self-Awareness

42. DETERMINANT FACTORS IN
COMMUNICATION
A client’s communication is affected by:
 Social Factors
 Religion
 Family Situation
 Level of Consciousness
 Stage of Illness
 Visual, Hearing and Speech Ability
 Language expertise

43. COMMUNICATION WITHIN THE
HEALTH CARE TEAM
 Providing care is a team effort.
 To ensure efficiency and effectiveness, effective
communication is necessary.
 This communication may be oral or written.

44. THE NURSE’S WAYS OF
COMMUNICATION
 Oral
 Written
 Self-Reflection

45. DOCUMENTATION

46. DOCUMENTATION
Written evidence of:
 The interactions between and among health care
professionals, clients, their families, and health care
organizations.
 The administration of tests, procedures, treatments,
and client education.
 The results of, or client’s response to, diagnostic tests
and interventions

47. DOCUMENTATION
 Documentation is the act of recording patient status
and care in written or electronic form, or in a
combination of the two forms.
 Is anything written or printed on which you rely as
record or proof of patient actions and activities.
 Documentation in the health record is an
integral(essential)part of safe and effective nursing
practice

48. DOCUMENTATION PURPOSE
 Communication
 Continuity of Care
 Quality Improvement
 Planning and Evaluation of Patient Outcomes
 Legal Documentation
 Professional Standards of Care
 Reimbursement and Utilization Review
 Education
 and Research

49. What Should be Documented in the Medical
Record?
 Identification Data.
 Medical History.
 Physical Examinations.
 Diagnostic And Therapeutic Order.
 Appropriate Consent.
 Reports Of Procedures.
 Results Of Tests.
 Conclusions At The Termination Of Care

50. CHARACTERISTICS OF
DOCUMENTATION
 Complete
 Correct
 Timely
 Legal
 Professional
 Brief OR concise
 Comprehensive
 Factual

51. METHODS OF DOCUMENTATION
 Narrative Charting
 Source-oriented charting
 Problem-oriented charting
 PIE charting
 Focus charting
 Charting by exception
 Computerized documentation
 Case management with critical paths

52. NARRATIVE CHARTING
 This traditional method of nursing documentation
takes the form of a story written in paragraphs.
 Before the advent of flow sheets, this was the only
method for documenting care.
 About 30% of nurses’ time, during an 8-hour shift.
 Time-consuming

53. SOURCE-ORIENTED CHARTING
 A narrative recording by each member (source) of
the health care team on separate records.
 Unstructured
 time-consuming

54. PROBLEM-ORIENTED CHARTING
 Was introduced in 1969 by Lawrence Weed.
 Developed on a medical model
 Structured
 Focuses on the client’s problem and employs a
structured, logical format called SOAP or or
SOAPIER charting

55. PROBLEM-ORIENTED CHARTING
o Subjective data (what the client states or family states)
o Objective data (what is observed/inspected)
o Assessment:Interpretation of meaning of subjective
and objective data
o Plan (actions to be taken to relieve client’s problem)

56. PROBLEM-ORIENTED CHARTING
Implementation: Specific interventions
Evaluation: Effectiveness of the plan
Revision: Recommended changes

57. PIE CHARTING
 Was introduced at Craven Regional Medical Center in
1984 to streamline documentation.
 PIE charting has a nursing origin.
 PIE is an acronym for:
o Problem
o Intervention
o Evaluation of Nursing care
Includes:
o flow sheet
o Nursing progress notes

58. FOCUS CHARTING
 Focus charting was created in 1981 at Eitel Hospital in
Minneapolis.
 A documentation method that uses a column format to
chart data, action, and response (DAR).
 Not limited to client “problems”
 but allows for the identification of all “concerns” (e.g.,
results of a diagnostic test)

59. CHARTING BY EXCEPTION (CBE)
 CBE was introduced in 1983 by St. Luke Medical Center
in Milwaukee.
 A documentation method that requires the nurse to
document only deviations from pre-established norms.
 Three key components:
o Flow sheets: Highlight significant findings
 Reference documentation: Is related to the
standards of nursing practice.
 Bedside accessibility : Is related to the documentation
forms.

60. COMPUTERIZED DOCUMENTATION
 Decreased documentation time.
 Increased legibility and accuracy.
 Clear, decisive, and concise words.
 Statistical analysis of data.
 Enhanced implementation of the nursing process.
 Enhanced decision making.
 Multidisciplinary networking.

61. CASE MANAGEMENT WITH CRITICAL
PATHS
 A comprehensive, standard plan of care for specific
case situations.
 The pathway is monitored to ensure that
interventions are performed on time and client
outcomes are achieved on time.

62. FORMS FOR RECORDING DATA
 Worksheets and Kardex
 Flow Sheets
 Nurse’s Progress Notes
 Discharge Summary
Other
o Report etc

63. WORKSHEETS AND KARDEX
 A summary worksheet reference of basic information
that traditionally is not part of the record. Usually
contains:
o Client data (name, age, marital status, religious
preference, physician, family contact).
o Medical diagnoses: listed by priority.
o Nursing diagnoses: Listed by priority
o Allergies.
o Medical orders (diet, medications, diagnostic tests, etc.).
o Activities permitted.

64. FLOW SHEETS
 Vertical or horizontal columns for recording dates
and times and related assessment and intervention
information. Also included are notes on:
o Client teaching.
o Use of special equipment.
o IV Therapy.

65. NURSE’S PROGRESS NOTES
 Used to document:
o Client’s condition, problems, and complaints.
o Interventions.
o Client’s response to interventions.
o Achievement of outcomes.
 Progress notes include the following forms:
o Nurses’ notes
o Medication administration
o intake and output
o teaching records etc

66. DISCHARGE SUMMARY
 Highlights client’s illness and course of care.
Includes:
o Client’s status at admission and discharge.
o Brief summary of client’s care.
o Intervention and education outcomes.
o Resolved problems and continuing care needs.
o Client instructions regarding medications, diet, food-
drug interactions, activity, treatments, follow-up and
other special needs.

67. Reports
 Are oral, written, or audiotape exchanges of
information between caregivers
 Reporting is the verbal communication of data
regarding the client’s health status, needs,
treatments, outcomes, and responses
(Eggland & Heinemann, 1994).

68. Types of Reporting
 Summary Reports
 Walking Rounds
 Telephone Reports and Orders

69. LEGAL DOCUMENTATION
 The medical record serves as a legal document for
recording all client activities assessed and initiated
by health care practitioners.

70. LEGAL DOCUMENTATION/ GENERAL
DOCUMENTATION GUIDELINES
 Stored according to all governing laws and also to the
policies of the hospital
 Use blue or black ink unless you are using a
computer or your hospital uses a special ink color for
different shifts.
 Do not use pencil or ink that can be erased.
 Write so that it can be read clearly

71. LEGAL DOCUMENTATION/ GENERAL
DOCUMENTATION GUIDELINES
 Date all of your notes.
 Write the time that you took your notes.
 Sign your full name and title (RN, LPN etc).
 Do not draw out things if you make a mistake.
 Write only the facts be professional and never add
personal comments or feelings.
 Do not use abbreviation unless they are accepted for
use by your hospital.
 Keep all medical records in a safe and secure place;

72. LEGAL DOCUMENTATION/ GENERAL
DOCUMENTATION GUIDELINES
 Do not allow anyone to touch or look at your medical
records unless they are a healthcare worker assigned
to take care of the patient;
 Do not discuss any facts of the patient or their care
with anyone other than the assigned healthcare staff
or the patient themselves.
 Identify the client and write legally ,Spell correctly.
 Record each phone call to a physician, including the
exact time, message, and response

73. CONCLUSION
 The basic components of the communication process are
the sender , message, channel, receiver, and feedback
 Communication is a dynamic process that is influenced
by culture, gender, past experiences, emotions .
 Therapeutic communication is used to ensure that
effective interpersonal communication occurs with the
patient .
 Documentation is a written form of communication that
is valuable for continuity of care, quality assurance, legal
evidence, reimbursement justification, research, and
education.