chapter 4 communicating with the health team all items and derived items © 2015, 2011 by mosby,...

Chapter 4

Communicating with the Health Team

All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

Health Team Communication

Health team members communicate with each other to give coordinated and effective care. They share information about:

• What was done for the person

• What needs to be done for the person

• The person’s response to treatment

2All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

Communication

Communication is the exchange of information.

For good communication: Use words that mean the same thing to you and

the receiver of the message. Use familiar words. Be brief and concise. Give information in a logical and orderly manner. Give facts and be specific.


The Medical Record

The medical record (chart, clinical record) is: A written or an electronic account of a person’s

condition and response to treatment and care A permanent, legal document

Nursing center policies about medical records and who can see them address: Who records When to record Abbreviations Correcting errors Ink color Signing entries


Medical Record

You have an ethical and legal duty to keep the person’s information confidential.

Under OBRA, residents have the right to the information in their medical records.

These forms relate to your work: The admission sheet Progress notes Activities of daily living (ADL) flow sheet Other flow sheets

The Kardex is a type of card file. It summarizes information found in the medical record.


Resident Care Conferences

OBRA requires two types of resident care conferences: Interdisciplinary care planning (IDCP) conference Problem-focused conference

The person has the right to take part in these planning conferences.


Reporting and Recording

Reporting is the oral account of care and observations.

Recording (charting) is the written account of care and observations.

During end-of-shift report, information is shared about: The care given The care that must be given The person’s condition Likely changes in the person’s condition


Recording

Anyone who reads your charting should know: What you observed What you did The person’s response


Recording Time (24-Hour Clock)


Medical Terminology

Prefixes, roots, and suffixes A prefix is a word element placed before a root. The root is the word element that contains the

basic meaning of the word. A suffix is a word element placed after a root.

Medical terms are formed by combining word elements. Prefixes always come before roots. Suffixes always come after roots. A root can be combined with prefixes, roots, and

suffixes.


Abdominal Regions

The abdomen is divided into the following regions: Right upper quadrant (RUQ) Left upper quadrant (LUQ) Right lower quadrant (RLQ) Left lower quadrant (LLQ)


Directional Terms

Directional terms give the direction of the body part when a person is standing and facing forward. Anterior (ventral)—at or toward the front of the body or body

part Distal—the part farthest from the center or from the point of

attachment Lateral—away from the midline; at the side of the body or

body part Medial—at or near the middle or midline of the body or body

part Posterior (dorsal)—at or toward the back of the body or body

part Proximal—the part nearest to the center or to the point of

origin


Abbreviations

Abbreviations are shortened forms of words or phrases. Use only those accepted by the center.


Computers in Health Care

Computer systems collect, send, record, and store information.

Computers do the following: They save time. They increase quality care and safety. Fewer errors are made in recording. Records are more complete. Staff is more efficient.


Phone Communications

Good communication skills are needed when answering phones. Be professional and courteous. Practice good work ethics. Follow the center’s policy.


Dealing with Conflict

If problems are not worked out, the following can happen: Unkind words or actions occur. The work setting becomes unpleasant. Care is affected. To resolve conflict, identify the real

problem. This is part of problem solving.


Problem Solving

The problem-solving process involves these steps: Step 1: Define the problem. Step 2: Collect information.

• The information must be about the problem.

Step 3: Identify possible solutions. Step 4: Select the best solution. Step 5: Carry out the solution. Step 6: Evaluate the results.


Guidelines for Managing Conflict

These guidelines can help you deal with conflict: Ask your supervisor for some time to talk privately. Approach the person with whom you have the conflict. Agree on a time and place to talk. Talk in a private setting. Explain the problem. Listen to the person. Identify ways to solve the problem. Set a date and time to review the matter. Thank the person for meeting with you. Carry out the solution. Review the matter as scheduled.


Quality of Life

Health team members must communicate with each other for effective and coordinated care.

False or incomplete information can harm the person.

Resident information is personal and confidential. Always protect the right to privacy.


chapter 4 communicating with the health team all items and derived items © 2015, 2011 by mosby,...

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