1. Dynamics of Care in Society Communication 1

2. Objectives:  Identify & define the concepts & elements of communication theory  Recognize a communication dilemma  Identify nonverbal aspects of communication  Utilize sensitivities & problem solvng skills to achieve interpersonal communication that occurs in the health delivery process

3.  Formulate appropriate communication strategies to detect & avert breakdowns in communication  Differentiate between open & closed ended questions  Develop skills to design open-ended questions  Determine the appropriate questions to ask patients  Be familiar with appropriate, caring responses  Know how to obtain help if there is a language barrier

5. Communication defined: a sharing of information or ideas, including content as well as the feelings or emotions Verbal & nonverbal behavior within a social context Listen…Talk to your doctor Listen…Talk to your doctor

6. Methods of COMMUNICATION One on one Small group Large audience Mass communication TV, radio, film, newspapers, internet

7. FORMS OF COMMUNICATION: 1. VERBAL: spoken words, manner, tone, non-language sounds (sighs or sobs) 2. NON-VERBAL: touch, eye contact, kinesics (body movement), proxemics (personal space) 3. WRITTEN: letters, memos, chart documentation, agendas, reports…

8. COMMUNICATION PROCESS Channel: medium Copy in Notes

9. Communication Process Flow of communication between a medical assistant and a patient

10. THE SENDER… The one who initiates the message or communication. Puts the thought, idea, experience or act into a form that can be transmitted.

11. THE MESSAGE… The thought, idea or expression from the sender. Often a dual message, verbal and nonverbal simultaneously.

12. THE RECEIVER… The one to whom the message is sent. The receiver is prompted (by the message), to analyze, interpret and respond.

13. THE FEEDBACK…

14. Observations Health care workers use their senses to: See Color of skin, swelling or edema Presence of rash or sore Color of urine or stool Amount of food eaten Touch Pulse Dryness or temperature of skin Perspiration Swelling Hearing Respirations Abnormal body sounds Coughs Speech Smell Body odor Unusual odors of breath, wounds, urine or stool (feces)

15. Educational/intellectual level: ex. medical terminology unfamiliar to patient Psychological/Emotional: grief, anger, anxiety, perceptions, pride, financial concerns Physiological: Impairments in cognition or hearing, age, sex, developmental stage COMMUNICATION CHALLENGES:

16. Video “Drew” AGT Communication Challenges

17. Communicating with the Hearing Impaired Use body language such as gestures and signs. Speak clearly in short sentences. Face the individual to facilitate lip reading. Write messages if necessary. Make sure hearing aids are working properly

18. Use a soft tone of voice. Describe events that are occurring. Announce your presence as you enter a room. Explain sounds or noises. Use touch when appropriate. Communicating with the Visually Impaired

19. These patients may have difficulty remembering the correct words, may not be able to pronounce certain words, and may have slurred speech. The health care worker must be patient Allow them to try and speak Encourage them to take their time Repeat the message to assure accuracy Encourage them to use gestures or point to objects Provide pen and paper if they can write Use pictures with key messages communicate Communicating with Patients with Aphasia or Speech Impediments

20. Eye contact – in some cultures, it’s not acceptable, and looking down is a sign of respect Terminal illness – in some cultures, the patient is NOT told his/her prognosis, and family members are responsible for making care decisions Touch – in some cultures, it is wrong to touch someone on the head. Others may limit touch between male and female Personal care – in some cultures, only family members provide personal care Culture/language barriers:

21. Stereotyping, prejudice, bias Stereotypes such as “dumb blonde” or “fat slob” cause us to make snap judgments about others that affect the communication process. Health care workers must learn to put prejudice aside and show respect for all individuals. Distractions: Attention, Environment, Hunger, Pain

22. (Texting…where does it fit?)

23. Encourage Sound open and positive. Be attentive. Fact Find Ask Questions(Who, What, Why, When, Where, & How). Avoid distractions Take notes Use strategies,,, Be an active & critical listener

24. Use reflections open ended questions statements to repeat back what you heard ex. “Mr. Wellness, you were saying that the new medication is making you vomit.” Use paraphrasing use your own words to restate what you heard ex. “it sounds as if you are saying you do not want to take the medication anymore”. Strategies

25. Use open ended questions to gain further information (activity…open vs closed ended questions) Ex. “Can you describe the type of pain?” Closed ended questions are necessary for times when specific information is required. Ex. “Are you in pain right now?” Summarize organize the information they have communicated and check back for accuracy

26. Use encouraging words that will invite them to continue on. "Mmm, hmm" "I see." "Right." “ Uh, huh." "Tell me more." "Sounds like you have some ideas on this." "I'm interested in what you have to say." "Let's talk about it." Listen with an accepting attitude.

27. Use nonverbal actions to show you are listening. relaxed posture head-nodding facial expression relaxed body expression eye contact Use Silence is natural and sometimes appropriate in conversations

28. Always make sure you have time to listen and talk before you start. If you want to encourage talk, avoid questions with ‘yes’, ‘no’, or just one word. Start with “Tell me about…” or “What do you think about…” You might start a conversation by mentioning a television show: “What do you think about the boys in that ad? Do you know anyone who is like that?” Show your interest in his or her life: “I hear prom is coming up. What do you think about it?” Conversation Starters

29. NEGATIVE IMPACTs ON COMMUNICATION Giving an opinion Offering false reassurances Being defensive Showing approval or disapproval Stereotyping Asking why Changing the subject inappropriately

30. Things to avoid while being an active listener Do not interrupt. Do not interrogate. Limit the number of questions you ask so that you are "drilling" them. Do not try to think of your response in your own head while you are listening. Do not change the subject.

31. Avoid phrases like: "Are you sure." "You shouldn't feel that way." "Its not that bad." “You're making something out of nothing." "Sleep on it. You'll feel better tomorrow." Do not be judgmental … allow speaker to feel that they can communicate questions and ideas.

32. Patient Interviews General guidelines Listen actively Ask appropriate questions Record information accurately Protect patient’s privacy Be organized Avoid attending to distractions Let patient know who will see her next and when Basic interview techniques Reflecting: using open-ended statements to repeat back what you have heard Paraphrasing: using your own words to repeat what you have heard Clarification: asking for an example or further details Open-ended questioning: what, when, how? Summarizing: reviewing what you have heard in a condensed form Silences: allowing time to formulate thoughts

33. New patient interviews Patient’s medical & family history Brief review of body systems Patient’s social history Patient’s medications Established patient interviews Review patient’s chart for health problems Ask questions about current medical problems & changes in health Ask about known allergies Record patient information Patient Education Assess Plan Implement Evaluate Document

34. NON-VERBAL COMMUNICATION

35. What is the message for each?

36. NON-VERBAL COMMUNICATION Includes: 1.Appearance 2.Kinesics or body movement Facial expressions Gestures Eye movement 3.Facial expressions 4.Posture & gait 5.Tone of voice 6.Touch Can create positive or negative feelings, Watch for nonverbal cues that show how the patient feels about being touched, Maintain proper personal space, position, & posture

37. How are these a reflection of professionalism ????? Give an example of how non-verbal clues create misperceptions ????? Watch power posture Watch power posture … 8.5 min 7. Eye contact 8. Proxemics (personal space) Larger when talking to a stranger Becomes smaller the better you know someone Typically larger between two men than between two women Differs from culture to culture

38. NON-VERBAL COMMUNICATION may vary with culture

40. What is the message for each? Handout…

41. TIPS FOR MAKING SURE PATIENTS WITH LOW HEALTH LITERACY (patients' ability to understand their disease and how to manage their care) …GET THE APPROPRIATE MEDICAL INFO 1. Look for patients who need help: A patient can read and write with average skill and still not understand the language you use. 2. Avoid jargon: many well-intentioned physicians make the mistake of using technical terms, then trying to define them. (also remember most Americans read at an 8 th grade level)

42. 3. Use the “teach back” method: Avoid asking patients, "Do you understand?" most will say they do even when they are confused. "I want to make sure I did a good job teaching you. Tell me how you are going to do this when you get home.“ Ask them to repeat your instructions in their own words. Watch this method

43. 5. Use pictures: Illustrations often convey instructions better than words. (Sample pictogram s on next slide) 6. Enlist the aid of a family member or friend or translator 4. Avoid unnecessary details: …yet be specific when necessary. Address one problem or issue at a time, or on separate meetings

44. Visuals For Communication Project

47. HAZARDOUS SUBSTANCE SYMBOLS

48. Dynamics of Care in Society Written Communication for Health Care Professionals 48

49. Written communication “practical writing”… for a specific purpose, ex: Reports Business letters Interoffice memos Manuals Forms Applications Chart documentation

50. “Practical Writing” Types Narrative writing…tells what happened, paragraph form, Descriptive writing…details of person, object, event Informative writing…giving directions, explaining how to, answering questions, making something easier to understand, use bullets or steps, Persuasive writing..giving an opinion or stating a point of view and supporting it with reasons in order to persuade the reader to accept or possibly take action on it

51. the oral account of care and observations the written account of care and observations. Recording the oral account of care and observations Reporting the written account of care and observations. Record patient information completely & precisely Record information only in secure & appropriate locations Record any action you take concerning a patient (“if it is not documented…it didn’t happen”)

52. report only what you saw, not the reasons.Just the facts… report only what you saw, not the reasons. –NOT – “Mrs. Jones is in pain.” –INSTEAD – “Mrs. Jones is holding her chest with wheezing as she breathes.” –Objective / Sign – what was seen or Observed –Subjective / Symptom - what the patient Said Minimize medical jargon (for a patient)

53. Get started… get comfortable, be concise, have logical transitions of thought Outline ideas… organize before you write * brainstorm * group similar ideas together * find unifying themes * have a beginning, middle, end Revising…check for… * clarity * sentence & paragraph structure Proofreading… refinement…check for… * grammar, punctuation, spelling * final touches Drafting hints…

54. Tips for… “Well & Clearly Written” - create an outline to clarify and order your concepts - write a really bad first draft with no rewriting - rewrite, read out loud, rewrite, read again and rewrite - have colleagues comment on your draft - trust feedback from reviewers and rewrite again - let it sit, return for a fresh read out loud, and finalize

55. For Research Assistance… UCLA Library under services menu tab choose references & research help UCLA Library

56. MEDICAL DOCUMENTATION

57. Purposes of documentation in HC 1. Communication among the health care team 2. Assessment (vital signs, hx, symptoms…) 3. Quality Assurance (competence & quality of care) 4. Reimbursement (verification for insurances…) 5. Legal Record (admission of evidence) 6. Education (use for training) 7. Research: Useful Data Gained From Patient Records

58. Examples: Nurse updates patient’s record with new info from patient Doctor sees nurse’s note & orders speech therapy consult to evaluate swallowing ability Pharmacist views medical history before filling prescription Discharge planner evaluates occupational therapist’s notes on progress in independence with ADL’s

59. Ease of access to data Multiple users simultaneously Different locations Various devices Easy storage & retrieval; faster recording of data Nearly unlimited file space Easy back-up for security Easy to add or attach info Improved legibility Advantages of Computerized Documentation

60. Safe Computer Recordkeeping 1.Don’t share passwords/computer signature 2.Don’t leave logged-on terminal unattended 3.Follow protocol for correcting errors 4.Allow only authorized personnel to create, change, or delete files 5.Back up records regularly 6.Don’t leave patient info displayed on monitor in view of others 7.Keep running log of electronic copies made of files 8.Never use unencrypted email to send protected health info 9.Follow confidentiality procedures for sensitive material

61. What you’ll find in the medical record…  Admission sheet – general demographic info, insurance info…  Graphic sheet – for vital signs…  Physician’s orders – for medications, instructions, procedures…  Progress notes – on patient’s progress, new or changing info from each of the members of the health care team  Medical history and exam – Allergies, Immunizations, Childhood diseases Current & past medications Previous illnesses, Surgeries, Hospitalizations

62.  Family medical history  Reports – test results, lab results, consultations…  Psycho-Social History Marital status Occupation Education Hobbies Diet Alcohol & tobacco use Sexual history  Miscellaneous – correspondence, AD, organ donor…

63. Good Medical Documentation Tips 1.It is accurate (ex. Correct spelling, Errors marked through, labeled with “error,” initialed, & dated…) 2.It is complete (ex. All supporting information – lab results …) 3.It is concise (ex. Only relevant information) 4.It is legible 5.It is organized (ex. Most recent information first, date stamped…)

64. Progress Notes --- 3 Types 1. SOAP notes Subjective data Statements from patient describing condition Symptoms experienced Objective data Data that provider can measure, see, feel, or smell Test results Vital signs Assessment Patient’s diagnosis Possible disorders to be ruled out Plan Description of what should be done Diagnostic tests Treatments Follow-up

65. 2. Charting by exception Covers only significant or abnormal findings Decreased charting time Greater emphasis on significant data Easy retrieval of significant data Timely bedside charting Standardized assessment Greater interdisciplinary communication Better tracking of important patient responses More cost effective

66. 3. Narrative  Paragraph format  Includes: Contact with patient What was done for patient Outcomes  Can be time-consuming to write & difficult to read  It is the oldest & least structured type

67. Handout… PROPER TELEPHONE COMMUNICATION ANSWERING…. 1.ANSWER PROMPTLY 2.IDENTIFY SELF 3.FIND OUT WHO IS CALLING 4.SPEAK COURTEOUSLY, CLEARLY & PLEASANTLY 5.USE DISCRETION IN RELEASING INFORMATION, REMEMBER CONFIDENTIALITY 6.END CALL GRACEFULLY

68. Handout… SCREENING…. 1.DON’T OFFEND CALLER 2.ASK WHO IS CALLING, NATURE OF BUSINESS OR EMERGENCY 3.ANSWER QUESTIONS TACTFULLY 4.ASK IF MESSAGE CAN BE LEFT 5.PLACE ON HOLD AND GET GUIDANCE, HELP IF NEEDED

69. TAKING A MESSAGE…. 1.OBTAIN TIME, DATE, NAME OF CALLER, PURPOSE OF CALL 2.TAKE NOTES, REPEAT INFO BACK TO CALLER FOR ACCURACY 3.USE MESSAGE FORMS & FOLLOW THOUGH WITH PASSING MESSAGE TO CORRECT RECIPIENT. Handout…

70. HANDLING COMPLAINTS…. 1.STAY CALM 2.GATHER INFO 3.BE SYMPATHETIC 4.OFFER TO FIND OUT WHAT CAN BE DONE 5.END CALL ON PLEASANT NOTE Handout…