ULO 6- Apply Sound Written and Communication Skills Flashcards
Define: Contemporaneous Documentation
you are documenting as and when you are giving care. Need to document every time you see the woman, do something for her
Explain: Principles of documentation
is:
- contemporaneous
- comprehensive
- logical
- legible and clear
- concise and accurate
- identifies author and designation
Explain: Critical writing
- uses comparison
- provides evidence for points made
- consider strengths and weaknesses
Explain: women-centred care and communication
omen want to make their own decisions about their pregnancy and birth experience, and strongly prefer a woman-centred approach to maternity care.
Communication among Professionals involved what key components
- mutual support and affirmation that the partnership is working well
- sharing accurate and appropriate information
- communication process must include the woman and her community
What are the NSW Health Mandatory Requirements for documentation
- Accurate description of each patient and client’s contact with a health professional
- A health care record is available for every patient
- Identification that must appear of every page of the health care record
- Unique identifier (medical record number, unique patient identifier)
- Patients family name and given name
- Date of birth (or gestational age)
- Sex (excluding ObstetriX records)
Documentation
Define: Addendum
if entry has forgotten additional detail it must be written under “addendum”
- include the date/time of the omitted event and the date/time of addendum
Documentation
Define: Written in error
must be used when an error has been made
- Draw a line through incorrect area/mistake
- Print name , sign, designation and date/time of correction
Define: Communication
a verbal or written message which employs a common system of signs, symbols or behaviour to exchange information
What factors can influence people’s communication
Culture
Language
Noise
Level of education
