Communication Flashcards
What does ISBARR stand for?
I-Identity/introduction
S- Situation
B – background
A-Assessment
R- Recommendation
R- Read back of orders/response
What does SOAP stand for in the SOAP note method?
Subjective, Objective, Assessment, and Plan
What does PIE stand for in PIE charting?
Problem, Intervention, and Evaluation
What are Source-Oriented Records?
Source-oriented records can often be found in rural areas where paper records are still available. Each section of the paper record may be divided into sections for the physician’s notes, nurse’s notes, images, labs, etc.
What is Focus Charting and what is its primary advantage?
Draws attention to the patient’s concern. The focus may be a patient’s strength, problem, or need. The primary advantage of focus charting is the holistic emphasis on the patient and the patient’s priorities
What is Charting by exception?
A method of documenting normal findings based on standardized normal, standards of practice, and predetermined criteria for assessments and interventions. Significant findings or exceptions to the predefined norms are only documented in detail. This is used a lot in major hospitals of acute care settings.
What are the four levels of communication?
intrapersonal, interpersonal, small-group, and organizational communication.
What is intrapersonal communication?
Intrapersonal (level 1) – Self talk, communication within yourself.
What is interpersonal communication?
Interpersonal (level 2) – Occur between two or more people with a goal to exchange messages. May happen with patients and families.
What are some examples of group communication?
Group – Small group (level 3) Staff meeting, teaching sessions
Organizational (level 4) review union policies
What happens during the orientation phase?
Nurse introduces themselves. May go over the plan of care with the patient and introduce the patient to the other people working on the unit and their names. Nurse and patient may develope a plan together.
Nurse may show the patient where the call button is, or how to use the hospital bed.
What happens during the working phase?
Patient and nurse are looking at what goals have been achieved and what can be achieved today. Patient and nurse work together.
What happens during the termination phase?
reflect with the patient regarding the goals that were met or still working towards but have made some progress, no matter how big or small. This is also when we’ll “terminate” the relationship, we’ll assess how the patient will cope with this termination.
