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2017 Spring Semester > Communication and Documentation > Flashcards

Communication and Documentation Flashcards

1
Q

Intrapersonal

A

occurs within individual

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2
Q

Interpersonal

A

one-to-one interaction between a nurse and another person

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3
Q

transpersonal

A

interaction that occurs within a persons spiritual domain

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4
Q

small group

A

interaction that occurs with a small number of persons

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5
Q

public

A

interaction with an audience

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6
Q

referent

A

motivates one person to communicate with another

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7
Q

Sender

A

Person who encodes and delivers the message

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8
Q

Reciever

A

Person who decodes the message

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9
Q

Channels

A

Means of conveying and receiving messages through the senses.

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10
Q

Message

A

Content of the communication

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11
Q

Feedback

A

Indicates whether the receiver understood the meaning of the sender’s message.

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12
Q

Interpersonal variables

A

Factors within both the sender and the receiver that influence communication

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13
Q

Environment

A

Setting for the sender-receiver interaction

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14
Q

Verbal communication

A

Code that conveys specific meaning through the combination of words

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15
Q

Connotative meaning

A

Interpretation of a words meaning influenced by the thoughts and feelings that people have about the word.

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16
Q

Intonation

A

Tone of voice

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17
Q

Timing

A

When a patient expresses an interest in communication

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18
Q

Pacing

A

Thinking before speaking and developing an awareness of the rhythm of your speech.

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19
Q

Clarity and Brevity

A

Simple, brief, and indirect.

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20
Q

Identify four zones of personal space

A
  1. Intimate zone
  2. Personal zone
  3. Socio-economic zone
  4. Public zone
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21
Q

Identify the four zones of touch

A
  1. Social zone (permission not needed)
  2. Consent Zone (permission needed)
  3. Vulnerable zone (special care needed)
  4. Intimate zone (permission and great sensitivity needed)
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22
Q

Pre-interaction phase

A 
(Before meeting a patient) 
Review data (medical and nursing history)
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23
Q

Orientation phase

A

Nurse and patient get to know one another

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24
Q

Working phase

A

Nurse and patient work together to solve problem and set goals

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25
Q

Termination phase

A

End of relationship

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26
Q

List the elements of professional communication

A
  • courtesy
  • use of names
  • trustworthiness
  • autonomy and responsibility
  • assertiveness
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27
Q

List the factors that can influence communication

A
  • attitudes, beliefs, values, and experiences
  • culture, education, and language
  • developmental level
  • gender
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28
Q

Active listening

A

Being attentive to what the patient is saying both verbally and non verbally.

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29
Q

Sharing observations

A

Helps the patient communicate without the need for extensive questioning.

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30
Q

Sharing empathy

A

Ability to understand and accept another persons reality.

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31
Q

Sharing hope

A

Sense of possibility

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32
Q

Sharing humor

A

Coping strategy to adjust to stress

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33
Q

Sharing feelings

A

Subjective feelings that results from ones thoughts and perceptions

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34
Q

Using touch

A

Most potent form of communication

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35
Q

Using silence

A

Useful when people are confronted with decisions that require much thought

36
Q

Providing information

A

Patients have the right to know about their health status and what is happening in their environment

37
Q

Clarifying

A

Restating an unclear or ambiguous message

38
Q

Focusing

A

Used to center on key elements or concepts of the message

39
Q

Paraphrasing

A

Restating another’s message more briefly using ones own words.

40
Q

Asking relevant questions

A

Seeking information needed for decision making

41
Q

Summarizing

A

Concise review of key aspects of an interaction.

42
Q

Self-disclosure

A

Subjectively true, personal experiences about self that are intentionally revealed to another

43
Q

Confrontation

A

Helping the patient become aware of inconsistencies in his or her feelings, attitudes, beliefs, and behaviors.

44
Q

Asking personal questions:

A

“Why don’t you and John get married?”

45
Q

Giving personal opinions

A

“If i were you, I’d put your mother in a nursing home”

46
Q

Changing the subject

A

“Lets not talk about your problems with the insurance company. It’s time for your walk.”

47
Q

Autonomic responses

A

“Older adults are always confused”

48
Q

False reassurance

A

“Don’t worry, everything will be all right”

49
Q

Sympathy

A

“I’m so sorry about your mastectomy;; it must be terrible to lose a breast.”

50
Q

asking for explanations

A

“Why are you so anxious?”

51
Q

Approval or disapproval

A

“You shouldn’t even think about assisted suicide; it is not right”

52
Q

Defensive responses

A

“No one here would intentionally lie to you”

53
Q

Passive responses

A

“Things are bad, and there’s nothing I can do abbot it”

54
Q

Arguing

A

“How can you say you didn’t sleep a wink? You were snoring all night long”

55
Q

A patient that cannot speak clearly

A

-listening attentively, do not interrupt , ask simple questions, allow time, use visual cues, do not shout, communication aids.

56
Q

Cognitively impaired

A

-simple sentences, ask one question at a time, allow time for response, be attentive, include family and friends.

57
Q

Hearing impaired

A

Check for hearing aids, reduce noise, get patients attention, face patient, sign language

58
Q

Visually impaired

A

Check for glasses, do not rely on gestures, indirect lighting.

59
Q

Unresponsive

A

-call patients by name, verbal and touch, explain all procedures, provide orientation

60
Q

Does not speak English

A

-normal tone, interpreter, avoid using family members, develop common aids.

61
Q

Communication

A

Means by which patients needs and progress, individual therapies, patient education, and discharge planning are conveyed to others.

62
Q

Legal documentation

A

Describes exactly what happens to the patient and must follow agency standards

63
Q

Diagnostic related groups

A

Classification system based on patients medical diagnoses that support reimbursement

64
Q

Education

A

Learning the nature of an illness and the individual patients responses.

65
Q

Research

A

Gathering of statistical data of clinical disorders, complications, therapies, recovery and deaths.

66
Q

Auditing

A

Objective, ongoing reviews to determine the degree to which quality improvement standards are met.

67
Q

Factual documentation

A

Contains descriptive, objective info about what a nurse observes, hears, palpates, and smells.

68
Q

Accurate documentation

A

Use of exact measurements establishes accuracy and helps determine patients condition.

69
Q

Complete documentation

A

Ensure report is complete, contains appropriate essential info.

70
Q

Current documentation

A

Timely entries (vitals, pain, meds)

71
Q

Organized documentation

A

Entered into a medial record facilities communication when it is documented in a logical order.

72
Q

Narrative

A

Story-like format that has the tendency to have repetitious information and be time consuming.

73
Q

Problem oriented medical record

A

Problem. Intervention, assessment, and plan

74
Q

SOAP

A

Subjective, objective, assessment, and plan

75
Q

SOAPIE

A

SOAP with intervention and evaluation added.

76
Q

PIE

A

Database, problem list, care plan, and progress notes.

77
Q

Electronic health record

A

Electronic record of patient information generated whenever a patient accesses medical care in any health care setting.

78
Q

Source record

A

separate each section for each discipline

79
Q

Charting by exception

A

Focuses on deviations from the established norm or abnormal findings; highlights trends and changes.

80
Q

Critical pathways

A

Multidisciplinary care plans that include patient problems, key interventions, and expected outcomes.

81
Q

Admission nursing history forms

A

Provides baseline data to compare with changes in the patients condition.

82
Q

Flow sheets

A

Provides current information that is accessible to all members of the health care team

83
Q

Kardex

A

Includes medications, diets, community resources, and follow up care.

84
Q

Acuity records

A

Level is based on type and number of nursing interventions required over a 24 hour period.

85
Q

Standardized care plans

A

Preprinted, established guidelines used to care for the patient.

86
Q

Discharge summary forms

A

Has activity, treatment, and nursing care pla sections that organize information for quick reference

87
Q

List guidelines the nurse should follow when receiving telephone orders from a health care provider

A
  • document every phone call you make
  • include when call was made
  • include who made the call
  • who was called
  • what information was given and what info was received

2017 Spring Semester (13 decks)

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