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CHARTING. DOCUMENTATION DATE DATE TIME TIME PLACE PLACE SIMPLE SIMPLE EXPLANATION TO TO WHOM WHO WHO WAS PRESENT WHAT WHAT WAS DONE SIGNATURE SIGNATURE.

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Presentation on theme: "CHARTING. DOCUMENTATION DATE DATE TIME TIME PLACE PLACE SIMPLE SIMPLE EXPLANATION TO TO WHOM WHO WHO WAS PRESENT WHAT WHAT WAS DONE SIGNATURE SIGNATURE."— Presentation transcript:

1 CHARTING

2 DOCUMENTATION DATE DATE TIME TIME PLACE PLACE SIMPLE SIMPLE EXPLANATION TO TO WHOM WHO WHO WAS PRESENT WHAT WHAT WAS DONE SIGNATURE SIGNATURE

3 INFORMED CONSENT Simple Consent Simple Consent Express consent Express consent Implied consent Implied consent Inadequate Consent Inadequate Consent

4 MALPRACTICE Depends on job description Depends on job description

5 MEDICAL RECORDS Chart contains everything Chart contains everything Entries must have date, time and signed with credentials Entries must have date, time and signed with credentials Abbreviations must be approved by institution. Abbreviations must be approved by institution.

6 GOOD SAMARITAN LAWS TO PROTECT PERSONS WHO GIVE MEDICAL AID IN EMERGENCY SITUATIONS. TO PROTECT PERSONS WHO GIVE MEDICAL AID IN EMERGENCY SITUATIONS. Cardiac Arrest Survival Act provides immunity for those who purchase Automatic External Defibrillators (AED). Cardiac Arrest Survival Act provides immunity for those who purchase Automatic External Defibrillators (AED).

7 COMMUNICATION Effective communication skills allow you to establish and maintain good working relationships with patients, patients’ families and other health care professionals.

8 FACTORS AFFECTING COMMUNICATION Perceptions Perceptions Values Values Personal Space Personal Space Emotions Emotions Sociocultural Background Sociocultural Background Knowledge Knowledge Environment Environment

9 COMMUNICATION PROCESS SENDERRECEIVER

10 VERBAL VERBAL NON-VERBAL: Stress; Contradict; Accent; Regulate; Substitute NON-VERBAL: Stress; Contradict; Accent; Regulate; Substitute LEVELS OF COMMUNICATION LEVELS OF COMMUNICATION Intrapersonal Intrapersonal Interpersonal Interpersonal

11 PERSONAL SPACE SOCIAL DISTANCE SOCIAL DISTANCE PERSONAL DISTANCE PERSONAL DISTANCE INTIMATE DISTANCE INTIMATE DISTANCE

12 LISTENING SKILLS MOST COMMUNICATION TIME IS SPENT LISTENING! Good eye contact Good eye contact Watch for non-verbal signs Watch for non-verbal signs Don’t cut patient off Don’t cut patient off Be comfortable with silence Be comfortable with silence

13 COMMUNICATION #1 CAUSE FOR LAW SUITS!! #1 CAUSE FOR LAW SUITS!!

14 CULTURAL DIFFERENCES Show respect Show respect Treat all equally Treat all equally Be aware of your own and patient’s nonverbal messages Be aware of your own and patient’s nonverbal messages If you do not understand something, ask for clarification If you do not understand something, ask for clarification Humor Humor Gender Gender

15 TIP In some cultures it is disrespectful to speak of the dead. Patient may be reluctant to provide detailed information on the family health history of dead relatives. Ask the patient if there has been any history of specific diseases in the family and not focus on the specific individual if that person is deceased. If unsuccessful, explain importance of this info, as it may provide clues to the patient’s condition. In some cultures it is disrespectful to speak of the dead. Patient may be reluctant to provide detailed information on the family health history of dead relatives. Ask the patient if there has been any history of specific diseases in the family and not focus on the specific individual if that person is deceased. If unsuccessful, explain importance of this info, as it may provide clues to the patient’s condition.

16 TIP Some Asian cultures calculate age from conception, not from the actual birth date. A newborn infant would be considered one year old. It is important to differentiate for pediatric patients because of the link between age and developmental milestones. Some Asian cultures calculate age from conception, not from the actual birth date. A newborn infant would be considered one year old. It is important to differentiate for pediatric patients because of the link between age and developmental milestones.

17 SPECIAL COMMUNICATION SITUATIONS Sensory Alterations Sensory Alterations Sensory Deficit Sensory Deficit Sensory Deprivation Sensory Deprivation Sensory Overload Sensory Overload Altered Consciousness Altered Consciousness Chemical Influence Chemical Influence Drug use Drug use Drug misuse Drug misuse Drug abuse Drug abuse

18 Patient Assessment Data Collection Data Collection Data Analysis Data Analysis Planning and Implementation Planning and Implementation Evaluation Evaluation

19 Data Collection Subjective: Anything the patient or person accompanying pt says that can affect the procedure Subjective: Anything the patient or person accompanying pt says that can affect the procedure Objective: What you see, hear, smell feel, or read in the patient’s chart Objective: What you see, hear, smell feel, or read in the patient’s chart

20 Data Analysis Integrate Critical thinking by listing all subjective and objective date, then analyze. Integrate Critical thinking by listing all subjective and objective date, then analyze. What data is relevant to the procedure? What data is relevant to the procedure?

21 Planning and Implementation After analyzing the data you come up with a plan to take the x-ray and implement. After analyzing the data you come up with a plan to take the x-ray and implement.

22 Evaluation Were the patient’s needs met? Were the patient’s needs met? Was the patient’s safety maintained? Was the patient’s safety maintained? Was the patient’s skin intact? Was the patient’s skin intact? Did the pt complain of pain during exam? Did the pt complain of pain during exam? What problems occurred that I didn’t plan for? What problems occurred that I didn’t plan for? Any discomfort to patient? Any discomfort to patient? Did I use higher-level critical thinking to complete procedure? Did I use higher-level critical thinking to complete procedure?

23 Activity John Gomez reports to the outpatient desk for a scheduled upright abdomen and UGI series. He states he feels ill and has had nausea and vomiting for 24 hours. His family is also ill. He is pale, sweating and dizzy when standing. He doesn’t think he will be able to swallow the barium What is the chief complaint? List objective and subjective data. What is your plan? John Gomez reports to the outpatient desk for a scheduled upright abdomen and UGI series. He states he feels ill and has had nausea and vomiting for 24 hours. His family is also ill. He is pale, sweating and dizzy when standing. He doesn’t think he will be able to swallow the barium What is the chief complaint? List objective and subjective data. What is your plan?

24 Developing Harmonious Relationship Establishing guidelines Establishing guidelines Reducing Distance Reducing Distance Listening Listening Using silence Using silence Responding to underlying message Responding to underlying message Restating main idea Restating main idea Reflecting main idea Reflecting main idea Seeking and providing Clarification Seeking and providing Clarification Making observations Making observations Exploring Exploring Validating Validating Focusing Focusing REFER TO TEXT REFER TO TEXT

25 AMERICANS WITH DIABILITIES ACT 1990 Congress passed this to provide civil rights protection to persons with disabilities Congress passed this to provide civil rights protection to persons with disabilities. Defines a disabled individual as “one who has a physical or mental impairment that substantially limits one or more major life activities” Defines a disabled individual as “one who has a physical or mental impairment that substantially limits one or more major life activities” Provides equal employment opportunity Provides equal employment opportunity

26 GREIVING PROCESS Denial Denial Anger Anger Bargaining Bargaining Depression Depression Acceptance Acceptance

27 CASE STUDY Mr. Gomez is an elderly Mexican-American patient who has come to the radiology department for an abdominal radiograph. He has been diagnosed with colon cancer and has undergone a surgical procedure that resulted in a colostomy. He speaks very little English. His wife and daughter are with him. His wife is visibly upset and uncomfortable being in the hospital. How would you explain the procedure to Mr. Gomez? Would you involve his family? Mr. Gomez is an elderly Mexican-American patient who has come to the radiology department for an abdominal radiograph. He has been diagnosed with colon cancer and has undergone a surgical procedure that resulted in a colostomy. He speaks very little English. His wife and daughter are with him. His wife is visibly upset and uncomfortable being in the hospital. How would you explain the procedure to Mr. Gomez? Would you involve his family? Mr Gomez us very uncomfortable lying flat on his back and says that he just wants to be left alone to die. How would you handle this situation? Mr Gomez us very uncomfortable lying flat on his back and says that he just wants to be left alone to die. How would you handle this situation?

28 DEATH AND DYING Communication issues Communication issues Be open to talk about anything dying pts want Be open to talk about anything dying pts want Discuss feelings about loss Discuss feelings about loss Listen!! Listen!! Dying Patient’s Rights Dying Patient’s Rights


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