LP9: Communication and Documentation

Question 1

What are the modes of communication?

Answer 1

*Verbal
*Non-verbal
*Electronic

Question 2

What does verbal communication include?

Answer 2

-Pace and intonantion
-Simplicity (vocabulary)
-Clarity and brevity
-Timing and relevance
-Adaptability
-Credibility
-Humor

Question 3

What does non-verbal communication include?

Answer 3

-Personal appearance
-Posture and gait
-Facial expressions
-Eye contact (culture may influence)
-Gestures

Question 4

What does electronic communication include?

Answer 4

-Electronic Health Records (EHR)
-Email

ADVANTAGES: Fast and efficient
DISADVANTAGES: Confidentiality issues, socioeconomics

Question 5

What types of personal space are there?

Answer 5

*Intimate touching 0-1.5ft
*Personal 1.5-4ft
*Social 4-12ft
*Public 12ft- beyond

Question 6

What is Elderspeaking?

Answer 6

Similar to babytalk (honey, sweetheart). It gives the message of dependence and incompetence to older adults.

Question 7

What is Therapeutic Communication?

Answer 7

Promotes understanding and can help establish a constructive relationship between the nurse and the client.

Question 8

What is Attentive Listening?

Answer 8

-Listening actively
-Requires energy and concentration
-Can be learned with practice

Question 9

What is Tuning In?

Answer 9

-Face the other person
-Open posture
-Lean toward
-Good eye contact
-Try to be relax

Question 10

What are the phases of a helping relationship?

Answer 10

*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

Question 11

What is SBAR?

Answer 11

-Situation
-Background
-Assessment
-Recommendation

Question 12

What is Assertive Communication?

Answer 12

POSITIVE

-Promotes client safety by minimizing miscommunication with colleagues
-The use of “I” statements
-Open to ideas
-Respects the rights of others

Question 13

What is Non-Assertive Communication?

Answer 13

NEGATIVE

-Submissive (Passive)
-Aggressive

Question 14

What is submissive communication?

Answer 14

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

Question 15

What is Aggressive Communication?

Answer 15

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

Question 16

What is Source-Oriented Record?

Answer 16

-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.

Question 17

What is Problem-Oriented Medical Record?

Answer 17

-Database
-Problem list
-Plan of care
-Progress notes
*SOAP
->Subjective & objective data, assessment, and plan

Question 18

What is PIE?

Answer 18

-Problems
-Interventions
-Evaluations
->Use flow sheets and progress notes

Question 19

What is Focus Charting?

Answer 19

-Data/time; focus; progress notes

-DAR -> data, action, response
-> Flow sheets and checklists are frequently used

Question 20

What is Charting by Exception (CBE)?

Answer 20

-Flow sheets
-Standards of nursing care
-Bedside access to chart forms

Only chart the abnormal

Question 21

What is Case Management?

Answer 21

-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