Communicating With the Health Team Chapter 6 Communicating With the Health Team Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Communicating With the Health Team Health team members communicate with each other to give coordinated and effective care. Health team members share information about: What was done for the person. What needs to be done for the person. The person’s response to treatment. You need to understand the aspects and rules of communication. Copyright © 2012 by Mosby, 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. A message sent is received and correctly interpreted by the intended person. If someone uses a strange term, ask what it means or use a dictionary. Avoid terms that the person and family do not understand. Do not wander in thought or get wordy. Organize your thoughts and present them step-by-step. The receiver should have a clear picture of what you are saying. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

The Medical Record The medical record is a written or electronic account of a person’s condition and response to treatment and care. The health team uses it to share information about the person. The medical record is a permanent, legal document. Often it is used months or years later if the person’s health history is needed. It can be used in court as legal evidence of the person’s problems, treatment, and care. The medical record is also called the chart or clinical record. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

The Medical Record (cont’d) The record has many forms. They are organized into sections. Each page has the person’s name, room and bed number, and other identifying information. Health team members record information on the forms for their departments. Agency policies about medical records address: Who records When to record Abbreviations Correcting errors Ink color Signing entries Other team members read the information. It tells the care provided and the person’s response. Some agencies allow nursing assistants to record observations and care. Others do not. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

The Medical Record (cont’d) You must know your agency’s policies about medical records and who can see them. The following parts of the medical record relate to your work. The admission record is completed when the person is admitted to the center. The health history (nursing history) is completed when the person is admitted. It contains the person’s background information and health history. Professional staff involved in a person’s care can review charts. You may know someone in the agency. If you are not involved in the person’s care, you have no right to review the person’s chart. You have an ethical and legal duty to keep the person’s information confidential. Patients and residents have the right to the information in their medical records. If the person or the person’s legal representative asks you for the chart, report the request to the nurse. Use the admission sheet to fill out other forms needing the same information. This avoids the person having to answer the same question many times. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

The Medical Record (cont’d) The graphic sheet is used to record measurements and observations made daily, every shift, or 3 to 4 times a day. Progress notes describe the care given and the person’s response and progress. Flow sheets are used to record frequent measurements or observations. The Kardex This is a type of card file that summarizes information in the medical record. It is a quick, easy source of information about the person. The graphic sheet includes vital signs, weight, intake and output, bowel movements, and doctor’s visits. The nurse records the following in the progress notes: Signs and symptoms Information about treatments and drugs Information about teaching and counseling Procedures performed by the doctor Visits by other health team members Review the Focus on Long-Term Care and Home Care: Progress Notes Box on p. 65 in the Textbook. Review the Focus on Long-Term Care and Home Care: Flow Sheets Box on p. 67 in the Textbook. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Reporting and Recording The health team communicates by reporting and recording. Reporting is the oral account of care and observations. Recording (charting) is the written account of care and observations. Reporting is the oral account of care and observations. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Copyright © 2012 by Mosby, an imprint of Elsevier Inc Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Reporting and Recording Time The 24-hour clock Communication is better with the 24-hour clock. The firs two digits are for the hours. The last two digits are for minutes. You must use AM and PM with conventional clock time and someone may forget to use AM or PM. This means that the correct time is not communicated and harm to the person could result. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Reporting Report to the nurse: Whenever there is a change from normal or a change in the person’s condition When the nurse asks you to do so When you leave the unit for meals, breaks, or for other reasons Before the end-of-shift (change-of-shift) report You report care and observations to the nurse. When reporting, follow the rules in Box 6-2 on p. 69 in the Textbook. The nurse needs your full attention when reporting. If distracted, you could omit or forget to give important things. Nurses must give their full attention when receiving reports. If someone is reporting to a nurse, do not interrupt unless the matter is urgent. You must not distract the nurse. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Reporting (cont’d) End-of-shift (change-of-shift) report The nurse reports information about: The care given The care to give during other shifts The person’s current condition Likely changes in the person’s condition In some agencies, the entire nursing team hears the end-of-shift report as they come on duty. In other agencies, only nurses hear the report. After the report, they share important information with nursing assistants. Review the Teamwork and Time Management: End-of-Shift Report Box on p. 70 in the Textbook. Review the Promoting Safety and Comfort: End-of-Shift Report Box on p. 70 in the Textbook. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Recording When recording on the person’s chart, you must communicate clearly and thoroughly. Anyone who reads your charting should know: What you observed What you did The person’s response Review the rules in Box 6-2 on p. 69 in the Textbook. Review the Focus on Communication: Recording Box on p. 71 in the Textbook. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Medical Terms and Abbreviations If you do not understand a word or phrase, communication does not occur. Medical terms are made up of parts or word elements. A term is translated by separating the word into its elements. Prefixes, roots, and suffixes Someone may use a word or phrase that you do not understand. Ask a nurse or use a medical dictionary. Review the contents of Box 6-3 on pp. 72-73 in the Textbook. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Medical Terms and Abbreviations (cont’d) A prefix is a word element placed before a root. Prefixes are always combined with other word elements. The root is the word element that contains the basic meaning of the word. It is combined with another root, prefixes, and suffixes. A suffix is a word element placed after a root. It changes the meaning of the word. Suffixes are not used alone. When translating medical terms, begin with the suffix. Medical terms are formed by combining word elements. Remember: Prefixes always come before roots. Suffixes always come after roots. A root can be combined with prefixes, roots, and suffixes. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Medical Terms and Abbreviations (cont’d) The abdomen is divided into regions. Abdominal regions are used to describe the location of body structures, pain, or discomfort. The regions are: Right upper quadrant (RUQ) Left upper quadrant (LUQ) Right lower quadrant (RLQ) Left lower quadrant (LLQ) See Figure 6-9 on p. 73 in the Textbook. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Copyright © 2012 by Mosby, an imprint of Elsevier Inc Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Medical Terms and Abbreviations (cont’d) 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 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 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 Certain terms describe the position of one body part in relation to another. See Figure 6-10 on p. 73 in the Textbook. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Medical Terms and Abbreviations (cont’d) Shortened forms of words or phrases Each agency has a list of accepted abbreviations. Use only those abbreviations on the list. If not sure about using an abbreviation, write the term out in full. Obtain a list of your agency’s accepted abbreviations when you are hired. Refer to the inside of the back book cover for common abbreviations. Review the Common terms that apply to basic care and safety in Box 6-4 on p. 74 in the Textbook. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Computers and Other Electronic Devices Computer systems collect, send, record, and store information (data). Data are retrieved when needed. Data are sent with greater speed and accuracy. You must follow the agency’s policies when using computers and other electronic devices. You must keep protected health information (PHI) and electronic PHI confidential. The health team uses computers and faxes to send messages and reports to the nursing unit. Computers are used for measurements such as blood pressure, temperature, and heart rate. If allowed access, you will learn how to use the agency’s system. You must maintain the confidentiality of protected health information (PHI) and electronic protected health information (e-PHI; EPHI) . Review the rules in Box 6-5 on p. 75 in the Textbook. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Phone Communications Good communication skills are needed. You give much information by: Your tone of voice How clearly you speak Your attitude You need to: Be professional and courteous. Practice good work ethics. Follow the agency’s policy. Follow the guidelines in Box 6-6 on p. 76 in the Textbook. Review the Focus on Long-Term Care and Home Care: Phone Communications Box on p. 76 in the Textbook. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Dealing with Conflict The problem-solving process involves these steps. Step 1: Define the problem. Step 2: Collect information 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. People bring their values, attitudes, opinions, experiences, and expectations to the work setting. Differences often lead to conflict. Conflict is a clash between opposing interests or ideas. If the problem is not worked out, the work setting becomes unpleasant. Care is affected. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Dealing With Conflict (cont’d) To deal with conflict: Ask your supervisor for some time to talk privately. Approach the person you have the conflict with. Agree on a time and place to talk. Talk in a private setting. Explain the problem and what is bothering you. 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. Communication and good work ethics help to prevent and resolve conflicts. Identify and solve problems before they become major issues. Review the Focus on Communication: Dealing With Conflict Box on p. 77 in the Textbook. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.