15/17 - Document/Communication Flashcards
Intrapersonal
Occurs within an individual (self-talk or inner thought)
Interpersonal
One-to-one interaction between two people
Transpersonal
Interaction within a person’s spiritual domain
Small-group
Interactions with a small number of people
Public
Interaction with an audience
Referent
Motivates one to communicate with another
Electronic health record (EHR)
Enhances communication among health care providers and thus patient safety
Supports effective health care delivery
EHR versus electronic medical record (EMR)
Includes tools to guide medication administration
Aids in quality improvement efforts and health care research
SOAPIE charting
Subjective data—objective data—assessment—plan—intervention—evaluation
PIE charting
Problem—intervention—evaluation
Acuity Rating Systems
Acuity ratings determine the hours of care and number of staff required for a given group of patients every shift or every 24 hours.
For example, in an acuity system, bathing patients is classified from 1 (very independent) to 5 (totally dependent in all aspects of care).
Transfer reports
Patients may transfer from one unit to another to receive different levels of care
(SBAR) technique
Situation—background—assessment—recommendation