1. Copyright © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Chapter 4 Communicating With the Health Team

2. Slide 2 Copyright © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.  Health team members communicate with each other to give coordinated and effective care. They share information about: They share information about:  What was done for the person  What needs to be done for the person  The person’s response to treatment

3. Slide 3 Copyright © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.  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 words that mean the same thing to you and the receiver of the message. Use familiar words. Use familiar words. Be brief and concise. Be brief and concise. Give information in a logical and orderly manner. Give information in a logical and orderly manner. Give facts and be specific. Give facts and be specific.

4. Slide 4 Copyright © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.  THE MEDICAL RECORD  The medical record (chart, clinical record) is: A written account of a person’s condition and response to treatment and care A written account of a person’s condition and response to treatment and care A permanent, legal document A permanent, legal document  Nursing center policies about medical records and who can see them address: Who records Who records When to record When to record Abbreviations Abbreviations Correcting errors Correcting errors Ink color Ink color Signing entries Signing entries

5. Slide 5 Copyright © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.  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 The admission sheet Progress notes Progress notes Activities-of-daily-living (ADL) flow sheet Activities-of-daily-living (ADL) flow sheet Other flow sheets Other flow sheets  The Kardex is a type of card file. It summarizes information found in the medical record. It summarizes information found in the medical record.

6. Slide 6 Copyright © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.  RESIDENT CARE CONFERENCES  OBRA requires two types of resident care conferences: Interdisciplinary care planning (IDCP) conference Interdisciplinary care planning (IDCP) conference Problem-focused conference Problem-focused conference  The person has the right to take part in these planning conferences.

7. Slide 7 Copyright © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.  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 given The care that must be given The care that must be given The person’s condition The person’s condition

8. Slide 8 Copyright © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.  Anyone who reads your charting should know: What you observed What you observed What you did What you did The person’s response The person’s response

9. Slide 9 Copyright © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc. Recording Time (24 hr. Clock)

10. Slide 10 Copyright © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.  MEDICAL TERMINOLOGY  Prefixes, roots, and suffixes A prefix is a word element placed before a root. A prefix is a word element placed before a root. The root is the word element that contains the basic meaning of the word. The root is the word element that contains the basic meaning of the word. A suffix is a word element placed after a root. A suffix is a word element placed after a root.  Medical terms are formed by combining word elements. Prefixes always come before roots. Prefixes always come before roots. Suffixes always come after roots. Suffixes always come after roots. A root can be combined with prefixes, roots, and suffixes. A root can be combined with prefixes, roots, and suffixes.

11. Slide 11 Copyright © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.  The abdomen is divided into the following regions: Right upper quadrant (RUQ) Right upper quadrant (RUQ) Left upper quadrant (LUQ) Left upper quadrant (LUQ) Right lower quadrant (RLQ) Right lower quadrant (RLQ) Left lower quadrant (LLQ) Left lower quadrant (LLQ)

12. Slide 12 Copyright © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.  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 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 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 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 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 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 Proximal—the part nearest to the center or to the point of origin

13. Slide 13 Copyright © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.  ABBREVIATIONS  Abbreviations are shortened forms of words or phrases. Use only those accepted by the center. Use only those accepted by the center.

14. Slide 14 Copyright © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.  COMPUTERS IN HEALTH CARE  Computer systems collect, send, record, and store information.  Computers do the following: They save time. They save time. They increase quality care and safety. They increase quality care and safety. Fewer errors are made in recording. Fewer errors are made in recording. Records are more complete. Records are more complete. Staff is more efficient. Staff is more efficient.

15. Slide 15 Copyright © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.  PHONE COMMUNICATIONS  Good communication skills are needed when answering phones. Be professional and courteous. Be professional and courteous. Practice good work ethics. Practice good work ethics. Follow the center’s policy. Follow the center’s policy.

16. Slide 16 Copyright © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.  DEALING WITH CONFLICT  If problems are not worked out, the following can occur: Unkind words or actions occur. Unkind words or actions occur. The work setting becomes unpleasant. The work setting becomes unpleasant. Care is affected. Care is affected.

17. Slide 17 Copyright © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.  The problem-solving process involves these steps: Step 1: Define the problem. Step 1: Define the problem. Step 2: Collect information. Step 2: Collect information.  The information must be about the problem. Step 3: Identify possible solutions. Step 3: Identify possible solutions. Step 4: Select the best solution. Step 4: Select the best solution. Step 5: Carry out the solution. Step 5: Carry out the solution. Step 6: Evaluate the results. Step 6: Evaluate the results.

18. Slide 18 Copyright © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.  These guidelines can help you deal with conflict: Ask your supervisor for some time to talk privately. Ask your supervisor for some time to talk privately. Approach the person with whom you have the conflict. Approach the person with whom you have the conflict. Agree on a time and place to talk. Agree on a time and place to talk. Talk in a private setting. Talk in a private setting. Explain the problem. Explain the problem. Listen to the person. Listen to the person. Identify ways to solve the problem. Identify ways to solve the problem. Set a date and time to review the matter. Set a date and time to review the matter. Thank the person for meeting with you. Thank the person for meeting with you. Carry out the solution. Carry out the solution. Review the matter as scheduled. Review the matter as scheduled.

19. Slide 19 Copyright © 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.  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. Always protect the right to privacy.