Mosby items and derived items © 2005 by Mosby, Inc.

Communication and Interpersonal Relationships
Vehicle for establishing a therapeutic relationship Means of influencing the behavior of another to lead to successful outcomes Vehicle for establishing a therapeutic relationship Means of influencing the behavior of another to lead to successful outcomes Mosby items and derived items © 2005 by Mosby, Inc.

Levels of Communication
Intrapersonal Interpersonal Transpersonal Small group Public Intrapersonal Interpersonal Transpersonal Small group Public Mosby items and derived items © 2005 by Mosby, Inc.

Basic Elements of Communication
Referent Sender and receiver Messages Channels Feedback Interpersonal variables Environment Referent Sender and receiver Messages Channels Feedback Interpersonal variables Environment Mosby items and derived items © 2005 by Mosby, Inc.

Forms of Communication
Verbal Nonverbal Symbolic Metacommunication Verbal Nonverbal Symbolic Metacommunication Mosby items and derived items © 2005 by Mosby, Inc.

Verbal Communication Vocabulary Denotative and connotative meaning Pacing Intonation Clarity and brevity Timing and relevance Vocabulary Denotative and connotative meaning Pacing Intonation Clarity and brevity Timing and relevance Mosby items and derived items © 2005 by Mosby, Inc.

Nonverbal Communication
Personal appearance Posture and gait Facial expression Eye contact Gestures Sounds Territoriality and personal space Personal appearance Posture and gait Facial expression Eye contact Gestures Sounds Territoriality and personal space Mosby items and derived items © 2005 by Mosby, Inc.

Zones of Personal Space
Intimate zone: 0 to 18 inches Personal zone: 18 inches to 4 feet Social zone: 4 to 12 feet Public zone: 12 feet and beyond Intimate zone: 0 to 18 inches Personal zone: 18 inches to 4 feet Social zone: 4 to 12 feet Public zone: 12 feet and beyond Mosby items and derived items © 2005 by Mosby, Inc.

Professional Helping Relationships
Nurse—client Nurse—family Nurse—health team Nurse—community Nurse—client Nurse—family Nurse—health team Nurse—community Mosby items and derived items © 2005 by Mosby, Inc.

Elements of Professional Communication
Courtesy Use of names Privacy and confidentiality Trustworthiness Autonomy and responsibility Assertiveness Courtesy Use of names Privacy and confidentiality Trustworthiness Autonomy and responsibility Assertiveness Mosby items and derived items © 2005 by Mosby, Inc.

Communication in the Nursing Process
Assessment Physical and emotional factors Developmental factors Sociocultural factors Gender Assessment Physical and emotional factors Developmental factors Sociocultural factors Gender Mosby items and derived items © 2005 by Mosby, Inc.

Communication in the Nursing Process (cont’d)
Nursing diagnosis examples Impaired verbal communication Anxiety Social isolation Ineffective coping Impaired social interaction Powerlessness Nursing diagnosis examples Impaired verbal communication Anxiety Social isolation Ineffective coping Impaired social interaction Powerlessness Mosby items and derived items © 2005 by Mosby, Inc.

Therapeutic Communication Techniques
Active listening (SOLER) Sharing observations Sharing empathy Sharing hope Sharing humor Sharing feelings Active listening (SOLER) Sharing observations Sharing empathy Sharing hope Sharing humor Sharing feelings Mosby items and derived items © 2005 by Mosby, Inc.

Therapeutic Communication Techniques (cont’d)
Using touch Using silence Providing information Clarifying Focusing Paraphrasing Using touch Using silence Providing information Clarifying Focusing Paraphrasing Mosby items and derived items © 2005 by Mosby, Inc.

Therapeutic Communication Techniques (cont’d)
Asking relevant questions Summarizing Self-disclosure Confrontation Asking relevant questions Summarizing Self-disclosure Confrontation Mosby items and derived items © 2005 by Mosby, Inc.

Nontherapeutic Communication Techniques
Asking personal questions Giving personal opinions Changing the subject Automatic responses False reassurance Sympathy Asking personal questions Giving personal opinions Changing the subject Automatic responses False reassurance Sympat Mosby items and derived items © 2005 by Mosby, Inc.

Nontherapeutic Communication Techniques (cont’d)
Asking for explanations Approval or disapproval Defensive responses Passive or aggressive responses Arguing Asking for explanations Approval or disapproval Defensive responses Passive or aggressive responses Arguing Mosby items and derived items © 2005 by Mosby, Inc.

Communication in the Nursing Process
Implementation Adapting communication techniques for clients with special needs Implementation Adapting communication techniques for clients with special needs Mosby items and derived items © 2005 by Mosby, Inc.

Standards Joint Commission on Accreditation of Healthcare Organizations (JCAHO) Joint Commission on Accreditation of Healthcare Organizations (JCAHO) Mosby items and derived items © 2005 by Mosby, Inc.

Purposes Maintenance and promotion of health and illness prevention Restoration of health Coping with impaired functioning Maintenance and promotion of health and illness prevention Restoration of health Coping with impaired functioning Mosby items and derived items © 2005 by Mosby, Inc.

Teaching Interactive process Conscious, deliberate set of actions Assist individuals to gain knowledge, change attitudes, adopt new behaviors, perform skills Interactive process Conscious, deliberate set of actions Assist individuals to gain knowledge, change attitudes, adopt new behaviors, perform skills Mosby items and derived items © 2005 by Mosby, Inc.

Role of the Nurse Ethical responsibility Response to client requests Identification of client needs Ethical responsibility Response to client requests Identification of client needs Mosby items and derived items © 2005 by Mosby, Inc.

Teaching as Communication
Referent Sender Message Channels Receiver Feedback Intrapersonal variables Referent Sender Message Channels Receiver Feedback Intrapersonal varia Mosby items and derived items © 2005 by Mosby, Inc.

Domains of Learning Cognitive learning Knowledge Comprehension Application Analysis Synthesis Evaluation Cognitive learning Knowledge Comprehension Application Analysis Synthesis Evaluation Mosby items and derived items © 2005 by Mosby, Inc.

Domains of Learning (cont'd)
Affective learning Receiving Responding Valuing Organizing Characterizing Affective learning Receiving Responding Valuing Organizing Characterizing Mosby items and derived items © 2005 by Mosby, Inc.

Domains of Learning (cont'd)
Psychomotor learning Perception Set Guided response Mechanism Complex overt response Adaptation Origination Psychomotor learning Perception Set Guided response Mechanism Complex overt response Adaptation Origination Mosby items and derived items © 2005 by Mosby, Inc.

Basic Learning Principles
Motivation to learn Ability to learn Developmental Physical Learning environment Motivation to learn Ability to learn Developmental Physical Learning environment Mosby items and derived items © 2005 by Mosby, Inc.

Teaching Process and Assessment
Expectations of learning Learning needs Motivation to learn Ability to learn Teaching environment Resources for learning Expectations of learning Learning needs Motivation to learn Ability to learn Teaching environment Resources for learning Mosby items and derived items © 2005 by Mosby, Inc.

Teaching Process and Nursing Diagnosis
Examples Deficient knowledge Ineffective health maintenance Impaired home maintenance Ineffective therapeutic regimen management Examples Deficient knowledge Ineffective health maintenance Impaired home maintenance Ineffective therapeutic regimen management Mosby items and derived items © 2005 by Mosby, Inc.

Teaching Process and Planning
Learning objectives Setting priorities Timing Organizing teaching material Maintaining attention and participation Building on existing knowledge Learning objectives Setting priorities Timing Organizing teaching material Maintaining attention and participation Building on existing knowledge Mosby items and derived items © 2005 by Mosby, Inc.

Teaching Process and Planning
Selection of teaching methods Availability of teaching resources Writing teaching plans Selection of teaching methods Availability of teaching resources Writing teaching plans Mosby items and derived items © 2005 by Mosby, Inc.

Teaching Tools Printed material Programmed instruction Computer instruction Non-print materials Diagrams, charts, pictures, objects, audiovisuals Printed material Programmed instruction Computer instruction Nonprint materials Diagrams, charts, pictures, objects, audiovisuals Mosby items and derived items © 2005 by Mosby, Inc.

Teaching Process and Implementation
Teaching approaches Telling Selling Participating Entrusting Reinforcing Teaching approaches Telling Selling Participating Entrusting Reinforcin Mosby items and derived items © 2005 by Mosby, Inc.

Teaching Process and Implementation (cont’d)
Incorporating teaching with nursing care Instructional methods One-on-one discussion Group instruction Preparatory instruction Demonstrations Incorporating teaching with nursing care Instructional methods One-on-one discussion Group instruction Preparatory instruction Demonstrations Mosby items and derived items © 2005 by Mosby, Inc.

Particular client needs Illiteracy and disabilities Cultural background and language Developmental stage Particular client needs Illiteracy and disabilities Cultural background and language Developmental stage Mosby items and derived items © 2005 by Mosby, Inc.

Teaching Process and Evaluation
Measurement methods Client expectations Documentation Measurement methods Client expectations Documentation Mosby items and derived items © 2005 by Mosby, Inc.

Chapter 26 Documentation and Informatics
Documentation is anything written or printed relating to the client. Documentation constitutes a fundamental tenant of nursing care. The information nurses communicate regarding their clients’ care reflects the quality of care and accountability for care provided. Accreditation agencies such as the Joint Commission specify guidelines for documentation. Nurses need to follow basic principles to maintain confidentiality during the transmittal of client information via verbal, written, or electronic media formats. Mosby items and derived items © 2005 by Mosby, Inc.

Confidentiality Nurses are legally and ethically obligated to keep client information confidential. Nurses are responsible for protecting records from all unauthorized readers. HIPAA act requires disclosure or requests regarding health information. Breaching confidentiality constitutes an egregious event. Students must be very cognizant of how they collect and transport client data. They must not have any client identifiers on their paperwork, including birth date, social security number, room number, medical record number. Mosby items and derived items © 2005 by Mosby, Inc.

Standards The Joint Commission requires each client have an assessment: Physical, psychosocial, environment, self-care, client education, and discharge planning needs Federal and state regulations, state statutes, standards of care, and accreditation agencies set nursing documentation standards. Make sure to discuss specific health care facility guidelines. The American Nurses Association standard of nursing documentation states that “documentation must be systematic, continuous, accessible, communicated, recorded and readily available to all members of the health care team”. The Joint Commission also expects a multidisciplinary care plan if more than one discipline cares for the hospitalized client. Mosby items and derived items © 2005 by Mosby, Inc.

Multidisciplinary Communication Within the Health Care Team
Records or chart: Confidential permanent legal document Reports: Oral, written, audiotaped exchange of information The client record contains an accurate account of the client's health status. The most common type of reports given by nurses includes change of shift reports, telephone reports, transfer reports, and incident reports. Remember the most current emphasis on reports for the handing over of patients includes SBAR: situation (briefly state the problem, chief complaints, what is it, when it happened or was reported, and how severe), background (pertinent background information related to the situation such as admitting diagnosis, list of current medications, allergies, IV fluids, most recent vital signs, lab results, and code status), assessment (What is the nurse’s assessment of the situation?), and recommendation (What is it the nurse’s recommendation or what does the nurse want?) Mosby items and derived items © 2005 by Mosby, Inc.

Multidisciplinary Communication Within the Health Care Team
Consultations: A professional caregiver providing formal advice to another caregiver Referrals: Arrangement for services by another care provider Consultations: A professional caregiver providing formal advice to another caregiver Referrals: Arrangement for services by another care provider Mosby items and derived items © 2005 by Mosby, Inc.

Purposes of Records Communication Legal documentation Financial billing Education Research Auditing/monitoring The client care record is a written account of the client’s needs and progress, individual therapies, content of client care conferences, client education, and discharge planning. The admitting nurse’s history and physical assessment contains biographical data, method of admission, reason for admission, past medical history, current medications, and review of risk factors. The medical progress notes detail the physician’s findings. Table 26-1 gives legal guidelines for recording. Remember, even if nursing care has been exemplary, “care not documented is care not provided.” DRGs have become the basis for establishing reimbursement for client care. A medical record audit reviews client care and at times determines reimbursement. As previously discussed in Chapter 25, client education is an important part of nursing practice. Research often determines changes made to nursing procedures and protocols. To improve quality of care, researchers collect and study statistical data from client records. The Joint Commission requires hospitals to establish quality improvement programs for conducting objective, ongoing reviews of all client care. Therefore, nurses perform auditing and monitoring programs. Mosby items and derived items © 2005 by Mosby, Inc.

Guidelines for Quality Documentation and Reporting
Factual Accurate Complete Current Organized Proper documentation is the best defense of legal claims associated with nursing care. Documentation must be clearly written and legible, individualized to the client. When charting, you must practice, you must use critical thinking, and you must use the nursing process. Table 26-2 presents examples of criteria for reporting and recording. Factual Accurate Complete Current Organized Mosby items and derived items © 2005 by Mosby, Inc.

Methods of Recording Narrative: The traditional method Problem-Oriented Medical Record (POMR): Database Problem list Nursing care plan Progress note Narrative: The traditional method Problem-Oriented Medical Record (POMR): Database Problem list Nursing care plan Progress note Mosby items and derived items © 2005 by Mosby, Inc.

Methods of Recording: Progress Notes
SOAP: Subjective, objective, assessment, plan SOAPIE: Subjective, objective, assessment, plan, intervention, evaluation PIE: Problem, intervention, evaluation Focus Charting (DAR): Data, action, response SOAP: Subjective, objective, assessment, plan SOAPIE: Subjective, objective, assessment, plan, intervention, evaluation PIE: Problem, intervention, evaluation Focus Charting (DAR): Data, action, response Mosby items and derived items © 2005 by Mosby, Inc.

Methods of Reporting Source records: A separate section for each discipline Charting by exception (CBE): Focuses on documenting deviations Case management plan and critical pathways: Incorporates a multidisciplinary approach to care Source records are separated into nursing, medicine, social work, respiratory therapy. The advantage is that care givers can locate each section to document entries. The disadvantage is that the clients’ problems are distributed across the record. CBE reduces documentation time and highlights trends or changes. The assumption with this method is that all standards are met unless otherwise documented. The disadvantage is that this system can pose legal risks if nurses are not disciplined in documenting exceptions. Case management model of delivering care incorporates a multidisciplinary approach to documenting client care. We discussed this in Chapter 2. Critical pathways are multidisciplinary care plans that include client problems, key interventions, and expected outcomes within an established time frame. Unexpected outcomes, unmet goals, and interventions not specified within the critical pathway time frame are called variances. Source records: A separate section for each discipline Charting by exception (CBE): Focuses on documenting deviations Case management plan and critical pathways: Incorporates a multidisciplinary approach to care Mosby items and derived items © 2005 by Mosby, Inc.

Common Record-Keeping Forms
Admission nursing history form Flow sheets and graphic records Client care summary or Kardex Acuity records Standardized care plans Discharge summary form Supply students with these forms. Help students fill out the forms. Have students practice before they enter into the hospital for the first time. Mosby items and derived items © 2005 by Mosby, Inc.

Home Care Documentation
Medicare has specific guidelines for establishing eligibility for home care. Documentation is the quality control and justification for reimbursement from Medicare, Medicaid, or private insurance. As hospital lengths of stay are shortened, larger numbers of older adults require home care services. Medicare has specific guidelines for establishing eligibility for home care. Documentation is the quality control and justification for reimbursement from Medicare, Medicaid, or private insurance. Mosby items and derived items © 2005 by Mosby, Inc.

Home Care Documentation
Nurses need to document all their services for payment. Nurses need to document all their services for payment. Mosby items and derived items © 2005 by Mosby, Inc.

Long-Term Health Care Documentation
Governmental agencies are instrumental in determining the standards and policies for documentation. The Omnibus Budget Reconciliation Act of 1987 includes Medicare and Medicaid legislation for long-term care documentation. The goal is a system of clinical documentation that improves care for residents and increases reimbursement for that care. Governmental agencies are instrumental in determining the standards and policies for documentation. The Omnibus Budget Reconciliation Act of 1987 includes Medicare and Medicaid legislation for long-term care documentation. Mosby items and derived items © 2005 by Mosby, Inc.

Long-Term Health Care Documentation
The department of health in states governs the frequency of written nursing records. The department of health in states governs the frequency of written nursing records. Mosby items and derived items © 2005 by Mosby, Inc.

Computerized Documentation
Software programs allow nurses to enter assessment data. Computers generate nursing care plans and document care. A complete computer-based patient care record (CPCR) is not without legal risks. Confidentiality in the access of records can cause a problem. HIPAA guidelines must be strictly adhered to. Nurses and students alike need orientation to computerized charting. Software programs allow nurses to enter assessment data. Computers generate nursing care plans and document care. A complete computer-based patient care record (CPCR) is not without legal risks. Mosby items and derived items © 2005 by Mosby, Inc.

Reporting Change of shift Telephone reports Verbal or telephone orders Transfer reports Incident reports Table 26-4 presents a comparison of proper and improper change-of-shift reporting. You can role play these reports with students. Remember to impress on students that they cannot take verbal orders or telephone orders. Remember to use SBAR. Change of shift Telephone reports Verbal or telephone orders Transfer reports Incident reports Mosby items and derived items © 2005 by Mosby, Inc.

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