Documentation and communication Flashcards
What are 5 important “rules”of case Recording
1) clear, accurate, and unbiased representation of the facts
2) a written record of all decisions
3) free of value judgements and subjective comments
4) timely
5) include only info that is directly relevant to delivery of services
What is the SOAP format of documentation
S (subjective)-clients perspective
O (objective)-vital signs, physical exams, lab tests, or objective indicators of problems like failing school, legal issues, etc…
A (assessment)-consolidation of objective and subjective findings into short assessment
P(plan)-what will be done as a consequence of the assessment
What is the communication concept of acceptance
Acknowledgement of “what is”
Recognizing the limits of ones control, but not accepting or excusing people’s behaviour or allowing it to continue
What is cognitive dissonance
When a person has to choose between 2 contradictory attitudes and beliefs
What are 3 ways to reduce cognitive dissonance
1) reduce importance of conflicting beliefs
2) acquire new beliefs that change the balance
3) remove the conflicting attitude or behaviour
What is meant by context
The circumstances surrounding human exchanges of info
What is a double bind
Offering 2 contradictory messages and prohibiting the recipient from noticing the contradiction
What is echoloalia
Repeating noises and phrases
Associated with catatonia, autism, schizophrenia, and other disorders
What is meant by information processing
Responses to info that are mediated through ones perception and evaluation of knowledge recieved
What is information processing block
Failure to perceive and evaluate potentially useful new info
What is metacommunication
The context within which to interpret the content of the message (ie. non verbal communication, body language, vocalizations)
What is meant by manifest content regarding communication
Concrete words or terms contained in communication
What is meant by latent content in regards to communication
That which is not visible
Underlying meaning of words or terms
