communication and documentation Flashcards
explain the communication process
The communication process is the; process of sending and receiving information
- a type of dynamic interactions between people and their environment using a process that involves celebration (thinking), cognition, hearing, speech production, and motor coordination
describe the modes and types of communication
Message - what is being communicated between the sender and receiver
Sender - the person who is relaying the message
Receiver - the person who is listening to the message
Feedback - a response to a message, either positive or negative
Channel - a communication model comprised of a sender-message-channel-receiver
describe the factors that influence communication
Verbal, non-verbal, emotional, energetic, and auditory
- what we say, our body language, what the receiver hears, what the speakers emotional state is, and how the speaker comes across all influence communication
describe the communication techniques necessary for developing a relationship with team members and clients
Being able to adapt to clients different needs and changing based on what they need
- work on modifying to the specific needs. If they had hearing aids, glasses, or something else make sure they have them. (Lowering the voice and speaking slower)
- be able to be in a good emotional state, don’t show off bad body language, and paying attention to what/how you say things
A postoperative care nurse is teaching a 76-year-old client who had cataract surgery about how to administer their eye drop medication after discharge. Which of the following forms of communication should the nurse use for this client?
verbal
A nurse manager is precepting a newly licensed nurse. At the end of the day, the nurse manager tells the newly licensed nurse, using a condescending tone and facial expression, that she did a good job considering her newness. Which of the following types and modes of communication are occurring here? (Select all that apply.)
passive aggressive
nonverbal
verbal
active listening
focusing on the client’s verbal and nonverbal messages
restating
paraphrasing what the client says to ensure understanding
reflection
used to reveal the feelings behind the message
open-ended questions
a technique used to get clients to disclose information
The nurse uses active listening to demonstrate attentiveness when talking with Ms. Hutchison. Which of the following actions should the nurse take when using this therapeutic communication technique? (Select all that apply.)
sit facing the client
make eye contact with the client
minimize distractions
Reflect on a time when someone wanted to talk with you about a concern. Drawing on your past experiences, what are some techniques you can use to help your clients communicate their feelings? (Enter your response and submit to compare to an expert’s response.)
To help clients communicate their feelings or concerns you should use therapeutic communication techniques including active listening, asking relevant questions, providing information, and silence. It is also helpful to share your observations about the situation, show empathy, and instill hope.
example of being critical of the client’s feelings
“and what exactly makes you say that?”
minimizing the client’s feelings
“don’t worry, things will get better soon”
changing the subject of the client’s concern
“perhaps you should focus on something else”
taking the focus of the conversation away from the client
“I know exactly how you feel”
When talking with Mr. Toledo about his concerns, which of the following statements should the nurse make to demonstrate therapeutic communication?
“Tell me more about what you mean when you say you don’t think you can do this.”
Recommendations for Communicating with Clients with Vision Loss
Identify and introduce yourself when you approach the client.
Tell the client when you are leaving the room.
Allow the person to take your arm.
Place the person’s hand on the back or arm of the seat.
Be specific when offering directions or use clock cues if the client is accustomed to this approach.
Examples: “Left about 10 feet” or “The door is at 10 o’clock.”
Provide medical information in large print, Braille, audio recording, printed information, or electronically using a computer-screen reading program.
Provide a reader who can effectively, accurately, and impartially read medical information to the client.
Recommendations for Communicating with Clients with Hearing Loss
Ask the client how they prefer to communicate and eliminate/minimize any background noise and distractions.
Ensure the assistive hearing device is working and the client is using it.
Before you speak, visually wave or lightly touch the client to get the client’s attention.
Do not exaggerate your words or raise your voice (unless requested to do so).
If the client lip reads, face them and keep your hands and objects away from your mouth.
Make appropriate eye contact, and do not turn away or walk around while communicating.
Understand that only 30% of lip reading is understood; therefore, be prepared to repeat information or questions.
Provide a sign language interpreter if necessary.
If an interpreter is present, speak directly to the client, not the interpreter, even if the client does not make eye contact with you. Pause occasionally to allow the interpreter time to translate accurately and completely. Provide real-time captioning and/or written material.
A nurse calls the unit to tell say that they will be late for their shift. The charge nurse responds, “Don’t worry, take your time and be safe.” After hanging up the phone, the charge nurse then says to staff at the nurses’ station, “I’m tired of that nurse always being late. I wish someone would do something about their tardiness.” Which of the following communication styles is the charge nurse demonstrating?
passive-aggressive
A nurse in the PACU is determining if a client has pain. The client is drowsy and opens their eyes to verbal stimuli but is unable to communicate their pain level. Which of the following actions should the nurse take?
use an alternative method for determining the client’s pain level
A nurse is instructing a client regarding heart-healthy activities. This action represents which of the following phases of the nurse-client relationship?
exploitation
A nurse enters a client’s room and stands near the client to ask them if they need anything. The client continues to watch the television, which is at a loud volume. Which of the following actions should the nurse take?
lower the volume on the television
A nurse is planning to teach new assistive personnel (AP) how to use a bedside glucose monitor to check a client’s blood glucose level. The nurse will include a 30-min face-to-face lecture and a written copy of the step-by-step procedure. Which of the following modes of communication is the nurse using in the teaching plan? (Select all that apply.)
verbal
written
nonverbal
A nurse in a provider’s office is caring for a client who has hypertension during a follow-up appointment and is focusing on the client’s ability to make healthy behavior changes. Which of the following statements by the nurse is an example of the use of affirmations?
“I’m glad you decided to continue your fitness routine”
A nurse manager is planning to introduce a new scheduling policy to the unit staff. Which of the following methods of communication should the nurse manager use?
schedule a face-to-face unit staff meeting
A hospice nurse is caring for a client who states that they want to have their last rites before they die. The nurse recognizes that which of the following factors is influencing the client’s request?
cultural factor
A nurse is assessing a client who came to the emergency department reporting chest pain. The client tells the nurse they have hearing loss and forgot to bring their hearing aid with them. Which of the following actions should the nurse take to improve communication with the client? (Select all that apply.)
move the client to a quiet area or private room
speak at a slower pace
avoid using medical terminology
A nurse is conducting a preoperative assessment of a client. Which of the following statements is an example of the nurse using motivational interviewing?
“you said that you’re sad. What is making you feel sad?”
A nurse receives a phone call from a client who was discharged yesterday. The client asks the nurse to email them a copy of their discharge instructions. Which of the following responses should the nurse make?
“I am unable to send your discharge instructions via email due to the HIPAA Privacy Act.”
A nurse is planning a presentation about skin care for a group of older adult clients at a senior center. Which of the following actions should the nurse take to enhance client learning?
ensure the room is well lit
A nurse is planning teaching for a client about wound care. Which of the following actions should the nurse take?
ensure the client is wearing their glasses or using hearing aids during teaching
A nurse is caring for a client who has refused to have a biopsy. The client states, “I don’t need the biopsy; I wouldn’t do anything about it anyways if it’s cancer.” The nurse replies, “You don’t want to have the biopsy because you would not seek treatment if it was cancer. Is that correct?” Which of the following therapeutic communication techniques is the nurse using?
restating
A nurse is providing discharge instructions to a client during a follow-up telephone call. Based on the Shannon-Weaver communication model, which of the following components of the model is the nurse demonstrating?
sender
A nurse is caring for a client who has dementia. Which of the following communication strategies should the nurse implement to communicate with the client?
speak to the client clearly and at a slow pace
A nurse is teaching a client who is newly diagnosed with diabetes mellitus. The client tells the nurse, “Thank you. I never really knew what caused diabetes.” Using the Schramm model of communication, the nurse should recognize the client’s statement as an example of which of following components of the model?
feedback
A nurse is planning to reconcile medications for a client who speaks a different language than the nurse. Which of the following actions should the nurse take?
request assistance from the facility’s interpreter
A nurse is obtaining a health history from a client who is newly admitted. The nurse notices that the client does not make eye contact and that their arms are folded across their chest. The nurse should recognize that the client is using which of the following forms of communication?
nonverbal
A nurse is caring for a client who has a new prescription for dialysis three times a week. The client avoids eye contact while talking to the nurse and explains that they work two jobs to support their partner and two children. The client also states, “I don’t know how I am going to have time for dialysis.” Which of the following factors are influencing the client’s communication? (Select all that apply.)
psychosocial factor
situational factor
A nurse is preparing to provide education to a group of newly licensed nurses about methods to enhance communication with clients. Which of the following statements should the nurse include? (Select all that apply.)
“respect the client during conversation”
“allow time for reflection during the conversation with the client”
“show empathy during the conversation with the client”
Difference between aggressive, passive, and passive-aggressive
Aggressive - communication that is verbally, and sometimes physically, abusive
Passive - avoids conflict, expressing feelings or opinions, or standing up for themselves when boundaries are crossed.
Passive-aggressive - communication that appears passive on the surface, but often, the individual is demonstrating anger is subtle, indirect, or secretive in a way.
Communication barrier example
A disturbed psychological and/or physiological state can alter a clients ability to communicate
Some therapeutic communication techniques
Open-ended questions
Silence
Active listening
Accepting
Restating/summarizing/paraphrasing
Reflection
identify the purpose and components of the health record system
The purpose is to track all events that happen, and keep a record of all transactions between the patients and the health care providers
- clinical data repository, decision support system, order entry system, patient portal, reporting system
the types of documentation in a health record
Treatment notes
Progress notes
Discharge summary
Admission paperwork
Documentation of treatments
the guidelines for accurate documentation in a health record
Keep the information factual, accurate, up to date, organized, and complete
In what situation is it acceptable to repeat back a verbal prescription without writing it down first?
in a sterile environment
Safeguards to prevent client harm when using verbal prescriptions include the following.
- Establish facility-specific regulations for verbal prescriptions.
- Confirm the correct client, and the presence of any allergies.
- Ensure verbal prescriptions include duration, indication, any specific instructions, and prescriber’s name.
- Use communication techniques to clarify words, letters, or numbers that sound alike.
- Document the prescription in the client’s record immediately.
- Employ read-back of all prescriptions to validate their accuracy with the prescriber.
- Resolve any discrepancies or concerns with the provider prior to implementing or preparing to carry out the prescription.
Which of the following actions is a step in receiving a verbal prescription?
ask the provider to spell out any words that are not clear
The video shows a nurse verifying a prescription entered through a computerized provider order entry (CPOE) system. Which are benefits of this form of prescription entry? (Select all that apply.)
transcription errors are reduced
medications can be more quickly administerd
Which of the following components of the client’s prescriptions require further clarification?
Ceftriaxone dose
timing of blood cultures
acetaminophen dose
reason for acetaminophen admin
ceftriaxone route
PCXR abbreviation
PCXR abbreviation
acetaminophen dose
ceftriaxone dose
reason for acetaminophen admin
who established HIPAA
it was established by the federal government with the goal of making healthcare more efficient
A staff nurse is evaluating a newly licensed nurse’s understanding of telephone prescriptions. Which of the following statements by the newly licensed nurse indicates an understanding of the information?
“I can take a telephone prescription if a provider is directing a cide for an unresponsive client.”
A nurse is caring for a client after a stroke. The nurse should recognize that which of the following individuals is allowed access to the client’s medical record without obtaining special consent from the client first?
The admitting provider, the charge nurse on the unit, the client
A nurse is reviewing documentation guidelines with a newly licensed nurse. Which of the following abbreviations should the nurse note as being on the joint commissions do not use list?
MSO4, IU, qhs
A newly licensed nurse is orienting to a facilities documentation process. The facility requires staff to on,y document variations from an expected set of findings when performing a physical assessment. The nurse should identify this system as which of the following documentation methods?
charting by exceptions
A nurse is discussing problem-oriented medical records with a group of newly licensed nurses. Which of the following information should the nurse include?
A problem-oriented medical record uses progress notes, which promotes information sharing among members of the interdisciplinary team.
A nurse is discussing the history of electronic health records (EHRs) during a staff in-service. The nurse should identify that which of the following agencies advocated for nationwide use of EHRs
the institute of medicine
A nurse is preparing to administer morphine 15 mg PO every 4 hr PRN pain for a client who has a new prescription. By which of the following routes should the nurse plan to administer the medication?
by mouth
A nurse is taking an admission history from a client who is concerned about the facility using an electronic documentation system. Which of the following should the nurse include as a benefit of electronic documentation?
The system alerts providers of possible actions that could cause client harm
A nurse is reviewing the documentation of a newly licensed nurse. Which of the entries should the nurse identify as meeting the American Nurses Association (ANA) standards of documentation?
“The client vomited 240 mL of clear emesis but denies pain or nausea”
A charge nurse is discussing health records with a newly licensed nurse. Which of the following information should the nurse identify as a component of a health record?
immunization data
A nurse is discussing legal regulations regarding medical records with a newly hired assistive personnel (AP). Which of the following information should the nurse include?
Facilities can establish their own rules for documentation methods
A nurse is reviewing documentation principals with a group of newly hired assistive personnel (AP). Which of the following should the nurse include?
A nurse who delegates a task to an AP will review the charting for that task
A nurse in the clinic is reviewing a clients prescriptions prior to discharge. The nurse should instruct the client that which of the following abbreviations indicates the medication can be taken as needed?
PRN
A nurse manager is reviewing the documentation of for newly licensed nurses. Which of the following medication entries should the nurse identify as being written correctly?
Synthroid 100 mg PO every morning ac
A charge nurse is reviewing soap documentation with a group of newly licensed nurses. Which of the following chart entries should the nurse include as an example of objective data?
Rebound tenderness noted in RLQ of the abdomen
nurse is reviewing characteristics of electronic documentation with staff at a providers office. Which of the following characteristics should the charge nurse plan to include?
Reduces medical errors, makes clients medical history more easily available, increases accuracy of coding procedures
A nurse is documenting information in a clients chart and makes the entry quotation mark client reports “abdominal pain on exertion”. Which of the following documentation format describes this entry?
The S in SOAP
A nurse is discussing computerized provider order entry systems with staff. Which of the following statements from a staff member indicates an understanding of a CPOE system?
CPOE systems can increase the speed of care delivery
A nurse is talking with a client about the electronic health record at the facility. Which of the following client statements indicates an understanding of EHRs?
I will be able to track my health information
A nurse is preparing an in-service about HIPAA. Which of the following information should the nurse plan to include?
Personnel can be terminated for breaching a client’s confidentiality
the health record
- Identifies health services provided
- Hospitalization
- Procedures
- Diagnostic Tests
- Many are now digital or electronic
- 1970s - The Department of Veteran Affairs started using EHRs
- 1997 – The Institute of Medicine (IOM) recommends the adoption of EHRs nationwide
- As of 2021, 96% of non-federal acute care hospitals in the U.S. use EHRs
- Only 75% of specialty hospitals have adopted us of a EHR
electronic health record
a systemic, digitized documentation system to improve client care
electronic health record info
- Provides comprehensive records
of a person’s health history - Is a means of communication for
all health care providers involved in
a client’s care. - Accounts for every treatment,
diagnosis, and provider visit for
billing - All components of an EHR can be
used in a court of law
electronic documentation guidelines
Never use anyone else’s login
information.
* don’t let anyone use yours
* Password must be strong, unique,
and should be changed frequently.
* Log off when documentation is
complete.
* Never leave a computer station
without logging off first.
* Computer monitor/screen should
be protected to avoid information
being seen by others.
* If an electronic signature is used,
ensure your name is correct and
professional credentials are noted.
documentation must be:
Must be:
* clear
* accurate
* concise
* accessible
- Provides a clear picture of the
client - Allows the interprofessional team
to communicate.
A nurse is providing teaching to a newly licensed nurse about the purpose of documentation in the client’s health record. Which of the following information should the nurse include?
A. Grants billing to review client care provided
B. Allows health care team members to document client care
C. Authorizes providers to co-sign on nurses’ notes
D. Allows nurses to document for other nurses on client care
B: allows health care team members to document client care
types of documentation
- Source-oriented medical records
- Problem-oriented medical records
- Subjective, objective, assessment, and plan charting (SOAP notes)
- Problem–intervention–evaluation charting (PIE model)
- Focus charting
- Charting by exception (CBE)
source-oriented documentation
- Traditional format for documenting
for all disciplines. - Divided into specific sections
- History and physical
- Progress notes
- Nurses’ notes
- Laboratory reports
- Diagnostic testing
problem-oriented medical records
- Stages include
- Developing a database (client’s history,
findings, diagnostics, and laboratory
results). - Identifying and numbering specific problems
based on the client’s history. The date the
problem is resolved is noted. - Formulating a plan of action for each
problem. - Noting ongoing progress for each problem.
- Developing a database (client’s history,
SOAP note
Subjective: Symptoms are what the client describes.
EX: 8/10 pain
* Objective: Clinical impression the health care provider sees, hears, touches,
measures, or smells.
EX: temp, resp, Bp, SPO2
* Assessment: Combines the subjective and objective information to arrive at a
nursing diagnosis.
EX: what the nurse has found
* Plan: Detailed steps to treat clients and the need for consultation or additional
testing to address client needs.
PIE model
Problem
Intervention
Evaluation
focus charting
- Centers on specific healthcare:
- Problems
- Changes in Condition
- Client Events
- Concerns
- Three items must be documented
(DAR). - Data
- Action
- Response
charting by exception
- This model focuses on documenting
only unexpected or unusual findings. - Involves the use of a physical
assessment flowsheet with
normal/expected findings. - Can be done in narrative format.
- Additional documentation is needed if
the client’s condition changes - Not the most effective form of
documentation
FACT
- All charting should be done
using the FACT acronym. - Factual
- Accurate
- Complete
- Timely
FACT -> factual
- Concrete
- Objective
- Descriptive
- Obtained from direct observation and measurement
- What the nurse sees, hears, smells, and feels.
FACT -> accurate
- Establish accuracy by including
- Exact descriptions
- Accurate measurements
- Providing concrete data for comparison of client condition over time
FACT -> complete
must contain:
what
when
where
why
how
FACT -> timely
- Documented in chronological order
- Chart throughout shift as events occur
- Give a better understanding of what is happening
correcting errors in documentation
- Mistakes with documentation do
occur. To fix those errors. - Keep the original document.
- Draw a single line through the entry
and write “error” along with your
initials. - Record the date and time of when the
correction was entered. - Do not obscure the original entry with
anything such as white out, black
permanent marker, pen, pencil, etc. - Document the correct information.
what color ink should you use when correcting mistakes in documentation
black or blue
guidelines for making a late charting entry
- Make sure to identify the entry as a
“late entry.” - Identify which event the late entry
is for. - Make sure all new entries are
signed and dated. - Identify which event or previous
note the new note is referencing. - Make sure there are no blank lines.
institute for safe medication practices
- The Institute for Safe Medication
Practices (ISMP) is devoted to
preventing errors that occur within
healthcare facilities. - The ISMP compiles a list of
abbreviations that are appropriate
to use with documentation, helping
to reduce confusion and errors.
