Communication and Documentation Flashcards
Intrapersonal
occurs within individual
Interpersonal
one-to-one interaction between a nurse and another person
transpersonal
interaction that occurs within a persons spiritual domain
small group
interaction that occurs with a small number of persons
public
interaction with an audience
referent
motivates one person to communicate with another
Sender
Person who encodes and delivers the message
Reciever
Person who decodes the message
Channels
Means of conveying and receiving messages through the senses.
Message
Content of the communication
Feedback
Indicates whether the receiver understood the meaning of the sender’s message.
Interpersonal variables
Factors within both the sender and the receiver that influence communication
Environment
Setting for the sender-receiver interaction
Verbal communication
Code that conveys specific meaning through the combination of words
Connotative meaning
Interpretation of a words meaning influenced by the thoughts and feelings that people have about the word.
Intonation
Tone of voice
Timing
When a patient expresses an interest in communication
Pacing
Thinking before speaking and developing an awareness of the rhythm of your speech.
Clarity and Brevity
Simple, brief, and indirect.
Identify four zones of personal space
- Intimate zone
- Personal zone
- Socio-economic zone
- Public zone
Identify the four zones of touch
- Social zone (permission not needed)
- Consent Zone (permission needed)
- Vulnerable zone (special care needed)
- Intimate zone (permission and great sensitivity needed)
Pre-interaction phase
(Before meeting a patient) Review data (medical and nursing history)
Orientation phase
Nurse and patient get to know one another
Working phase
Nurse and patient work together to solve problem and set goals
Termination phase
End of relationship
List the elements of professional communication
- courtesy
- use of names
- trustworthiness
- autonomy and responsibility
- assertiveness
List the factors that can influence communication
- attitudes, beliefs, values, and experiences
- culture, education, and language
- developmental level
- gender
Active listening
Being attentive to what the patient is saying both verbally and non verbally.
Sharing observations
Helps the patient communicate without the need for extensive questioning.
Sharing empathy
Ability to understand and accept another persons reality.
Sharing hope
Sense of possibility
Sharing humor
Coping strategy to adjust to stress
Sharing feelings
Subjective feelings that results from ones thoughts and perceptions
Using touch
Most potent form of communication
Using silence
Useful when people are confronted with decisions that require much thought
Providing information
Patients have the right to know about their health status and what is happening in their environment
Clarifying
Restating an unclear or ambiguous message
Focusing
Used to center on key elements or concepts of the message
Paraphrasing
Restating another’s message more briefly using ones own words.
Asking relevant questions
Seeking information needed for decision making
Summarizing
Concise review of key aspects of an interaction.
Self-disclosure
Subjectively true, personal experiences about self that are intentionally revealed to another
Confrontation
Helping the patient become aware of inconsistencies in his or her feelings, attitudes, beliefs, and behaviors.
Asking personal questions:
“Why don’t you and John get married?”
Giving personal opinions
“If i were you, I’d put your mother in a nursing home”
Changing the subject
“Lets not talk about your problems with the insurance company. It’s time for your walk.”
Autonomic responses
“Older adults are always confused”
False reassurance
“Don’t worry, everything will be all right”
Sympathy
“I’m so sorry about your mastectomy;; it must be terrible to lose a breast.”
asking for explanations
“Why are you so anxious?”
Approval or disapproval
“You shouldn’t even think about assisted suicide; it is not right”
Defensive responses
“No one here would intentionally lie to you”
Passive responses
“Things are bad, and there’s nothing I can do abbot it”
Arguing
“How can you say you didn’t sleep a wink? You were snoring all night long”
A patient that cannot speak clearly
-listening attentively, do not interrupt , ask simple questions, allow time, use visual cues, do not shout, communication aids.
Cognitively impaired
-simple sentences, ask one question at a time, allow time for response, be attentive, include family and friends.
Hearing impaired
Check for hearing aids, reduce noise, get patients attention, face patient, sign language
Visually impaired
Check for glasses, do not rely on gestures, indirect lighting.
Unresponsive
-call patients by name, verbal and touch, explain all procedures, provide orientation
Does not speak English
-normal tone, interpreter, avoid using family members, develop common aids.
Communication
Means by which patients needs and progress, individual therapies, patient education, and discharge planning are conveyed to others.
Legal documentation
Describes exactly what happens to the patient and must follow agency standards
Diagnostic related groups
Classification system based on patients medical diagnoses that support reimbursement
Education
Learning the nature of an illness and the individual patients responses.
Research
Gathering of statistical data of clinical disorders, complications, therapies, recovery and deaths.
Auditing
Objective, ongoing reviews to determine the degree to which quality improvement standards are met.
Factual documentation
Contains descriptive, objective info about what a nurse observes, hears, palpates, and smells.
Accurate documentation
Use of exact measurements establishes accuracy and helps determine patients condition.
Complete documentation
Ensure report is complete, contains appropriate essential info.
Current documentation
Timely entries (vitals, pain, meds)
Organized documentation
Entered into a medial record facilities communication when it is documented in a logical order.
Narrative
Story-like format that has the tendency to have repetitious information and be time consuming.
Problem oriented medical record
Problem. Intervention, assessment, and plan
SOAP
Subjective, objective, assessment, and plan
SOAPIE
SOAP with intervention and evaluation added.
PIE
Database, problem list, care plan, and progress notes.
Electronic health record
Electronic record of patient information generated whenever a patient accesses medical care in any health care setting.
Source record
separate each section for each discipline
Charting by exception
Focuses on deviations from the established norm or abnormal findings; highlights trends and changes.
Critical pathways
Multidisciplinary care plans that include patient problems, key interventions, and expected outcomes.
Admission nursing history forms
Provides baseline data to compare with changes in the patients condition.
Flow sheets
Provides current information that is accessible to all members of the health care team
Kardex
Includes medications, diets, community resources, and follow up care.
Acuity records
Level is based on type and number of nursing interventions required over a 24 hour period.
Standardized care plans
Preprinted, established guidelines used to care for the patient.
Discharge summary forms
Has activity, treatment, and nursing care pla sections that organize information for quick reference
List guidelines the nurse should follow when receiving telephone orders from a health care provider
- 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
