1. Communicating with the Health Team
Chapter 4
Communicating with the Health Team
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2. Health Team Communication
Health Care Workers 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 basic aspects and rules of communication.
Then you can learn how to communicate information to the nursing and health teams.
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3. Communication 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 facts and be specific.
In an exchange of information, a message sent is received and correctly interpreted by the intended person.
Give the receiver a clear picture of what you are saying.
If you do not know what a term means, ask the nurse.
Avoid using words with more than one meaning.
Present your thoughts step-by-step.
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4. 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
The health team uses the medical record to share information about the person.
The record can be used in court as legal evidence of the person’s problems, treatment, and care.
The Omnibus Budget Reconciliation Act of 1987 (OBRA) refers to the medical record as the clinical record.
Review Figs. 4-1 on p. 52 and 4-2 on p. 53.
Professional staff involved in a person’s care can review charts.
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5. 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.
IDCP conferences are held regularly to review and update care plans. It is also held to develop care plans for new residents.
Problem-focused conferences are held when one problem affects a person’s care. Only staff directly involved with the problem attend.
When you attend conferences, always share your ideas and observations.
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6. 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
The health team communicates by reporting and recording (Fig. 4-7 on p. 56).
If you have a question, ask the nurse to look at what you are trying to describe.
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, before the end-of-shift report. When reporting, follow the rules in Box 4-1 on p. 57.
The end of shift is a time for good teamwork. Continue to do your job. Your attitude is important.
Review Teamwork and Time Management: End-of-Shift Report on p. 56.
Review Promoting Safety and Comfort: End-of-Shift Report on p. 57.
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7. Recording Anyone who reads your charting should know:
What you observed
What you did
The person’s response
When recording on the person’s chart, you must communicate clearly and thoroughly.
Review the rules for reporting and recording in Box 4-1 on p. 57.
The charting sample in Figure 4-8 on p. 58 shows how the rules apply.
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8. Recording Time (24-Hour Clock)
The 24-hour clock (military time or international time) has four digits. The first two digits are for the hours: 0100 = 1:00 AM; 1300 = 1:00 PM. The last two digits are for minutes: 0110 = 1:10 AM.
The AM and PM abbreviations are not used.
The hour is the same for morning times, but AM is not used. For PM times add 12 to the clock time. If it is 2:00 PM, add 12 and 2 for For 8:35 PM, add 12 and 835 for 2035.
Some centers use 0000 for midnight. Others use Follow agency policy.
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9. 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.
Medical terms and abbreviations are used in health care. Someone may use a term that you do not understand. Ask the nurse or use a medical dictionary.
Prefixes and suffixes are not used alone; they are combined with other word elements.
To translate a term, the term is separated into its word elements.
To translate medical terms, begin with the suffix.
Eponyms are proper names assigned to diseases or procedures such as the Heimlich maneuver or Alzheimer’s disease.
Review Box 4-3 on p. 59 on medical terminology.
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10. Right upper quadrant (RUQ) Left upper quadrant (LUQ)
Abdominal Regions
Right upper quadrant (RUQ)
Left upper quadrant (LUQ)
Right lower quadrant (RLQ)
Left lower quadrant (LLQ)
The four regions of the abdomen are used to describe the location of body structures, pain, or discomfort (Fig on p. 61).
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11. Directional Terms
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
Directional terms describe the position of one body part in relation to another (Fig on p. 61).
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12. Abbreviations Abbreviations are shortened forms of words or phrases.
Use only those accepted by the center.
BM- Bowel Movement
BP- Blood pressure
P- Pulse
R- Respirations
PRN- as needed
Some abbreviations are unsafe to use because they have more than one meaning or can be misinterpreted, especially when handwritten.
Obtain a list of accepted abbreviations when you are hired.
Acronyms are pronounceable abbreviations, such as CABG (coronary artery bypass graft).
Review the common health care terms and phrases in Box 4-4 on p. 62.
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13. Computers in Health Care
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.
Computers are used for measurements such as blood pressures, temperatures, and heart rates.
Computers store vast amounts of information. Therefore the right to privacy must be protected.
Each staff member using computers and other electronic devices is issued a “unique user identification” and a password.
You must follow the center’s policies when using computers and other electronic devices. You must keep protected health information (PHI) and electronic protected health information (ePHI; EPHI) confidential.
Review Box 4-5 on p. 63 in the textbook.
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14. Good communication skills are needed when answering phones.
Phone Communications
Good communication skills are needed when answering phones.
Be professional and courteous.
Practice good work ethics.
Follow the center’s policy.
You will answer phones at the nurse’s station or in resident rooms. You need good communication skills.
Even though the caller cannot see you, you give much information by your tone of voice, how clearly you speak, and your attitude.
Behave as if you are speaking to someone face-to-face.
Follow the center’s policy and the guidelines in Box 4-6 on p. 63.
Some nursing centers do not allow nursing assistants to carry their cell phones with them while they work. This policy assures the assistant is giving residents undivided attention.
Pictures or audio recordings of residents should never be taken with a cell phone. This would be a violation of the person’s privacy.
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15. 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.
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.
Conflicts arise over issues or events. Work schedules, absences, and the amount and quality of work performed are examples.
Care is affected if the problem is not worked out.
See Focus on Communication: Dealing with Conflict on p. 64.
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16. 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.
Communication and good work ethics help prevent and resolve conflicts.
Identify and solve problems before they become major issues.
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17. 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.
You may find it hard to talk to someone with whom you have a conflict. This is hard for many people. However, letting the problem or issue continue only makes the matter worse.
Communication and good work ethics help to prevent and resolve conflicts.
Review Focus on Communication: Dealing with Conflict on p. 64.
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