Communication Flashcards
Recording
Care not recorded is care not given!
What is communication
The exchange of information
Does verbal or nonverbal communication send a stronger message?
Nonverbal
What is verbal communication?
Anything involving words, including sign language
Good communication techniques
Eye contact
Active listening
Actually listening
Ask open eneded questions
Be present, pay attention
Bad communication techniques
Interrupting
Assuming, rather than getting clear info
Talking roo fast
What is an observation?
Using Senses to collect information
Objective
Signs, factual
Subjective
Symptoms, opinions, feelings
What is an incident report?
A document filled out if something goes wrong, not part of a medical record
What are some rules of charting?
Use black ink
write legibly
everything written with date and time including year
never document for someone else
use patients name
only use approved abbreviations should be objective use patients own words if they say something
don’t leave blank spaces
be brief but accurate.
What should be including when reporting?
-Change in condition
-response to treatment
-complaints of pain
-refusals
-requests for clergy
In a liability situation, care not–
recorded is care not provided
