LP9: Communication and Documentation Flashcards
What are the modes of communication?
*Verbal
*Non-verbal
*Electronic
What does verbal communication include?
-Pace and intonantion
-Simplicity (vocabulary)
-Clarity and brevity
-Timing and relevance
-Adaptability
-Credibility
-Humor
What does non-verbal communication include?
-Personal appearance
-Posture and gait
-Facial expressions
-Eye contact (culture may influence)
-Gestures
What does electronic communication include?
-Electronic Health Records (EHR)
-Email
ADVANTAGES: Fast and efficient
DISADVANTAGES: Confidentiality issues, socioeconomics
What types of personal space are there?
*Intimate touching 0-1.5ft
*Personal 1.5-4ft
*Social 4-12ft
*Public 12ft- beyond
What is Elderspeaking?
Similar to babytalk (honey, sweetheart). It gives the message of dependence and incompetence to older adults.
What is Therapeutic Communication?
Promotes understanding and can help establish a constructive relationship between the nurse and the client.
What is Attentive Listening?
-Listening actively
-Requires energy and concentration
-Can be learned with practice
What is Tuning In?
-Face the other person
-Open posture
-Lean toward
-Good eye contact
-Try to be relax
What are the phases of a helping relationship?
*Pre-interaction phase (Knowing about the patient before meeting them face to face; getting report)
*Introductory phase (introducing yourself)
*Working phase (building trust)
*Resolution phase
What is SBAR?
-Situation
-Background
-Assessment
-Recommendation
What is Assertive Communication?
POSITIVE
-Promotes client safety by minimizing miscommunication with colleagues
-The use of “I” statements
-Open to ideas
-Respects the rights of others
What is Non-Assertive Communication?
NEGATIVE
-Submissive (Passive)
-Aggressive
What is submissive communication?
Discounts personal rights, diminished sense of self-worth, avoid problems.
*Problem doesn’t get resolved
*Lingering hurt feelings
*Person hopes that the problem will just go away, which rarely happens
What is Aggressive Communication?
Directed toward what one wants without considering the feelings of others; overreacts; blames others
-Use of “you” statements which puts the listener in a defensive position
What is Source-Oriented Record?
-Traditional client record
-Each dept makes notations in a separate section
-Narrative charting-written notes about routine care, normal findings, and client problems. Many agencies combine narrative with another system.
What is Problem-Oriented Medical Record?
-Database
-Problem list
-Plan of care
-Progress notes
*SOAP
->Subjective & objective data, assessment, and plan
What is PIE?
-Problems
-Interventions
-Evaluations
->Use flow sheets and progress notes
What is Focus Charting?
-Data/time; focus; progress notes
-DAR -> data, action, response
-> Flow sheets and checklists are frequently used
What is Charting by Exception (CBE)?
-Flow sheets
-Standards of nursing care
-Bedside access to chart forms
Only chart the abnormal
What is Case Management?
-Emphasizes quality, cost-effective care within an established length of stay
-Multidisciplinary approach using critical pathways (outcomes to be met each day)
-Work best for a client with 1 or 2 diagnoses
