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 2 All 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. 3 All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

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

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

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

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

Recording   Anyone who reads your charting should know:   What you observed   What you did   The person’s response 8 All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

Recording Time (24-Hour Clock) 9 All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

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

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

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

Abbreviations   Abbreviations are shortened forms of words or phrases.   Use only those accepted by the center. 13 All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

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

Phone Communications   Good communication skills are needed when answering phones.   Be professional and courteous.   Practice good work ethics.   Follow the center’s policy. 15 All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

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

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

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

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