Communicating With the Health Team
l Health team members communicate with each other to give coordinated and effective care.
n They share information about:
l What was done for the person
l What needs to be done for the person
l The person’s response to treatment
n COMMUNICATION
l Communication is the exchange of information.
l For good communication:
n Use words that mean the same thing to you and the receiver of the message.
n Use familiar words.
n Be brief and concise.
n Give information in a logical and orderly manner.
n Give facts and be specific.
n THE MEDICAL RECORD
l The medical record (chart, clinical record) is:
n A written account of a person’s condition and response to treatment and care
n A permanent, legal document
l Nursing center policies about medical records and who can see them address:
n Who records
n When to record
n Abbreviations
n Correcting errors
n Ink color
n Signing entries
l You have an ethical and legal duty to keep the person’s information confidential.
l Under OBRA, residents have the right to the information in their medical records.
l These forms relate to your work:
n The admission sheet
n Progress notes
n Bedside or ADL flow sheet
n Other flow sheets
l The Kardex is a type of card file.
n It summarizes information found in the medical record.
n REPORTING AND RECORDING
l Reporting is the oral account of care and observations.
l Recording (charting) is the written account of care and observations.
l During end-of-shift report, information is shared about:
n The care given
n The care that must be given
n The person’s condition
l Anyone who reads your charting should know:
n What you observed
n What you did
n The person’s response
n MEDICAL TERMINOLOGY
l Prefixes, roots, and suffixes
n A prefix is a word element placed before a root.
n The root is the word element that contains the basic meaning of the word.
n A suffix is a word element placed after a root.
l Medical terms are formed by combining word elements.
n Prefixes always come before roots.
n Suffixes always come after roots.
n A root can be combined with prefixes, roots, and suffixes.
l The abdomen is divided into the following regions:
n Right upper quadrant (RUQ)
n Left upper quadrant (LUQ)
n Right lower quadrant (RLQ)
n Left lower quadrant (LLQ)
l Directional terms give the direction of the body part when a person is standing and facing forward.
n Anterior (ventral)—at or toward the front of the body or body part
n Distal—the part farthest from the center or from the point of attachment
n Lateral—away from the midline; at the side of the body or body part
n Medial—at or near the middle or midline of the body or body part
n Posterior (dorsal)—at or toward the back of the body or body part
n Proximal—the part nearest to the center or to the point of origin
n ABBREVIATIONS
l Abbreviations are shortened forms of words or phrases.
n Use only those accepted by the center.
n COMPUTERS IN HEALTH CARE
l Computer systems collect, send, record, and store information.
l Computers do the following:
n They save time.
n They increase quality care and safety.
n Fewer errors are made in recording.
n Records are more complete.
n Staff is more efficient.
Computer Documentation
Hand-held devices
n PHONE COMMUNICATIONS
l Good communication skills are needed when answering phones.
n Be professional and courteous.
n Practice good work ethics.
n Follow the center’s policy.
n DEALING WITH CONFLICT
l If problems are not worked out, the following can occur:
n Unkind words or actions occur.
n The work setting becomes unpleasant.
n Care is affected.
l The problem-solving process involves these steps:
n Step 1: Define the problem.
n Step 2: Collect information.
l The information must be about the problem.
n Step 3: Identify possible solutions.
n Step 4: Select the best solution.
n Step 5: Carry out the solution.
n Step 6: Evaluate the results.
l These guidelines can help you deal with conflict:
n Ask your supervisor for some time to talk privately.
n Approach the person with whom you have the conflict.
n Agree on a time and place to talk.
n Talk in a private setting.
n Explain the problem.
n Listen to the person.
n Identify ways to solve the problem.
n Set a date and time to review the matter.
n Thank the person for meeting with you.
n Carry out the solution.
n Review the matter as scheduled.