Copyright © 2011, 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Chapter 6 Communicating With the Health Team

Copyright © 2011, 2007, 2003, 1999 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: What was done for the person What was done for the person What needs to be done for the person What needs to be done for the person The person’s response to treatment The person’s response to treatment Slide 2

Copyright © 2011, 2007, 2003, 1999 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 familiar words.  Be brief and concise.  Give information in a logical and orderly manner.  Give facts and be specific. Slide 3

Copyright © 2011, 2007, 2003, 1999 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 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 Slide 4

Copyright © 2011, 2007, 2003, 1999 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  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. Slide 5

Copyright © 2011, 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. 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. Slide 6

Copyright © 2011, 2007, 2003, 1999 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 that must be given  The person’s condition  Likely changes in the person’s condition Slide 7

Copyright © 2011, 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.  Anyone who reads your charting should know:  What you observed  What you did  The person’s response Slide 8

Copyright © 2011, 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Recording Time (24-hour Clock) Slide 9

Copyright © 2011, 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. 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. Slide 10

Copyright © 2011, 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.  The abdomen is divided into the following regions:  Right upper quadrant (RUQ)  Left upper quadrant (LUQ)  Right lower quadrant (RLQ)  Left lower quadrant (LLQ) Slide 11

Copyright © 2011, 2007, 2003, 1999 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  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 Slide 12

Copyright © 2011, 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Abbreviations  Abbreviations are shortened forms of words or phrases.  Use only those accepted by the center. Slide 13

Copyright © 2011, 2007, 2003, 1999 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 increase quality care and safety.  Fewer errors are made in recording.  Records are more complete.  Staff is more efficient. Slide 14

Copyright © 2011, 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Phone Communications  Good communication skills are needed when answering phones.  Be professional and courteous.  Practice good work ethics.  Follow the center’s policy. Slide 15

Copyright © 2011, 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. 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. Slide 16

Copyright © 2011, 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.  The problem-solving process involves these steps:  Step 1: Define the problem.  Step 2: Collect information. The information must be about the problem. 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. Slide 17

Copyright © 2011, 2007, 2003, 1999 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.  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. Slide 18

Copyright © 2011, 2007, 2003, 1999 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. Slide 19