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Chapter 6 Communicating with the Health Team Slide 1 Copyright © 2004 Mosby, Inc. All rights reserved.

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  • 1.Chapter 6 Communicating with the Health TeamCopyright 2004 Mosby, Inc. All rights reserved.Slide 1

2. Communication Open and honest communication is needed for a successful partnership. Is the exchange of information For good communication: Use words that mean the same thing to the sender and the receiver. Use familiar words. Be brief and concise. Give information in a logical and orderly manner. Give facts, and be specific. 3. Medical Record (Chart) The medical record is a written account of a person's condition and response to treatment and care. The record has many forms. Health team members record information. Agencies have policies about medical records. Policies generally cover abbreviations, signing entries, and correcting errors. Parts of the medical record relate to your work. 4. Medical Record (Chart) includes: Admission sheet Nursing history Graphic sheet Progress notes Flow sheets ADL flow sheet 5. The Kardex Is a Type of Card File A summary of the Medical Record DO NOT ATTEMPT PATIENT CARE WITHOUT *FIRST VIEWING THE KARDEX 6. Reporting and Recording Agency policies: Abbreviations, Signing entries, and Correcting errors Report Your care and observations are reported to the nurse. Record Safety / Care Measures what the client needed What was observed What was done The person's response 7. Reporting and Recording The 24-hour clock Ex: 11:42am would read as 1142 2100 1752 1313 2330 1615 1130 8. Medical Terminology and Abbreviations Medical terms are made up of parts of words or word elements. Prefixes, roots, and suffixes Abdominal regions (quadrants) Directional terms (medial, lateral, inferior) Know abbreviations Know medical terms Know prefixes, root, and suffixes See page 72-73 9. Using Computers The right to privacy must be protected. 10. Telephone Communications Be professional and courteous. Practice good work ethics. Maintain patients privacy. Follow the agencys policy. 11. Dealing with Conflict Define the problem. Collect information. Identify possible solutions. Select the best solution. Carry out the solution. Evaluate the results. 12. THEEND