1. NUR-102 SPRING 2015 BELINDA LOWRY, MSN, RN, CCRN COMMUNICATION & DOCUMENTATION

2. TICKET TO ENTRY https://www.corexcel.com/courses/Documentation -Web-Handout.pdf https://www.corexcel.com/courses/Documentation -Web-Handout.pdf Print test, complete, and bring to class on day of lecture.

3. GOOD MORNING!

4. COMMUNICATION Essential part of patient-centered care Effective communication helps prevent errors and injuries, and ensures high-quality patient care Maintains effective relationships

5. COMMUNICATION

6. INTERPERSONAL RELATIONSHIPS Nurse-patient relationship is a partnership with equal participants Being attentive to the patient will improve the likelihood that patient’s needs are being met Body language just as important as verbal language

7. COMMUNICATION SKILLS Critical thinking promotes effective communication Self-confidence can reassure the patient Fairness and integrity Humility

9. FORMS OF COMMUNICATION Verbal Vocabulary Denotative & connotative Pacing Intonation Clarity & brevity Timing & relevance Nonverbal Personal appearance Posture & gait Facial expression Eye contact Gestures Sounds Territoriality & personal space

10. ELEMENTS OF PROFESSIONAL COMMUNICATION Courtesy Use of names Trustworthiness Autonomy & Responsibility Assertiveness

11. NONTHERAPEUTIC TECHNIQUES Asking personal questions Giving personal opinions Changing the subject False reassurance Arguing Sympathy Asking for explanations Approval or disapproval Defensive, passive, or aggressive responses

12. NONTHERAPEUTIC COMMUNICATION https://www.youtube.com/watch?v=W 1RY_72O_LQ

13. THERAPEUTIC TECHNIQUES Active Listening Sharing observations Sharing empathy Sharing hope Sharing humor Sharing feelings Using touch Clarifying Asking relevant questions Summarizing Paraphrasing Self-disclosure

14. NCLEX PRACTICE The nurse has a patient who is short of breath and calls the health care provider using SBAR to help with the communication. What does the nurse first address? A. The respiratory rate is 28. B. The patient has a history of lunch cancer. C. The patient is short of breath. D. He or she requests an order for a breathing treatment.

15. NCLEX PRACTICE The statement that best explains the role of collaboration with others for the patient's plan of care is which of the following? A. The professional nurse consults the health care provider for direction in establishing goals for patients. B. The professional nurse depends on the latest literature to complete an excellent plan of care for patients. C. The professional nurse works independently to plan and deliver care and does not depend on other staff for assistance. D. The professional nurse works with colleagues and the patient's family to provide combined expertise in planning care.

16. NCLEX PRACTICE Identify behaviors that foster the development of trust. (Select all that apply.) A. Turning on the TV to her favorite show. B. Pulling the curtain to provide privacy. C. Offering to discuss information about her condition. D. Asking her why she is crying. E. Sitting quietly by her bed and holding her hand.

17. BREAK

19. DOCUMENTATION Proof of patient actions & activities Must be accurate, comprehensive, complete, and true Illustrates quality of care the patient received Helps facilitate communication among the health care team

20. CONFIDENTIALITY All patient information is confidential HIPAA: Health Insurance Portability and Accountability Act Only those who have a direct need to access a record may do so Cannot access your family, your own, your friends’, your coworkers’ No pictures, no social media Works both ways Patient has a right to limit any and all information given out Passwords, code words, “Jane/John Doe” pseudonyms

21. BLOG, JUNE 3, 2013 Patient John Smith, 123 Candy Lane, was in out clinic today. He turned 63 yesterday and is complaining of chest pain. He admits to not taking his blood pressure medication regularly and to poor management of his diabetes. We are so frustrated!

22. BLOG, JUNE 3, 2013 We saw one of our patients today in clinic. We know him well, as he also delivers for the Jimmy Johns on Main Street. He turned 63 yesterday and now has chest pain. He admits to not taking his BP meds regularly and to not managing his diabetes as instructed.

23. BLOG, JUNE 3, 2013 I am so frustrated with some of our patients. Take the person I saw today. I have spent so much time trying to help this person but she just won’t follow my advice. She is forgetful about taking her medications and won’t try any ideas for improving that situation. People, listen to your nurse!

24. BLOG, JUNE 3, 2013 ( FROM A DERMATOLOGIST ) Check out this link. (link). This is a great news story on CNN about one of our patients, talking about what it is like to battle leukemia. He has been our patient for many years. It is great to hear his positive statements about surviving long term with cancer.

25. PURPOSES OF RECORDS Communication Reimbursement Education Research Auditing & monitoring

26. GUIDELINES Factual Accurate Complete Current Organized

27. METHODS OF DOCUMENTATION Paper & Electronic Health Records (EHR) Narrative Problem-oriented SOAP Subjective, Objective, Assessment, Plan PIE Problem, Intervention, Evaluation Charting by exception Flow sheets/charts Kardex & Patient Summary Standardized care plans

28. REPORTING Hand-off report Shift report, any transfer of care Telephone report & orders Incident report SBAR Situation, Background, Assessment, Recommendation

30. BOX 26-4: GUIDELINES FOR TELEPHONE & VERBAL ORDERS Clearly determine the patient's name, room number, and diagnosis. Repeat any prescribed orders back to the physician or health care provider. Use clarification questions to avoid misunderstandings. Write TO (telephone order) or VO (verbal order), including date and time, name of patient, the complete order; sign the name of the physician or health care provider and nurse. Follow agency policies; some institutions require telephone (and verbal) orders to be reviewed and signed by two nurses. The health care provider must co-sign the order within the time frame required by the institution (usually 24 hours).

38. TIPS Base your documentation on your objective assessment findings using your senses of sight, touch, hearing, and smell. Document at the same time as the intervention if you can, or as close to it as possible. Beware of the following shortcomings in documentation that could allow an attorney to raise questions about the quality of care you gave the patient. Don't leave space so you can add more documentation later. Keep your personal opinions out of the record. However, without editorializing, you should factually and objectively document the patient's behavior (including any failure to adhere to treatment) if it's relevant to his care.

39. NCLEX PRACTICE You are supervising a beginning nursing student who is documenting patient care. Which of the following actions require you to intervene? The nursing student: A. Documented medication given by another nursing student B. Included the date and time of all entries in the chart. C. Stood with his back against the wall while documenting on the computer D. Signed all documents electronically.

40. NCLEX PRACTICE A patient asks for a copy of her medical record. The best response by the nurse is to: A. State that only her family may read the record. B. Indicate that she has the right to read her record. C. Tell her that she is not allowed to read her record. D. Explain that only health care workers have access to her record.

41. NCLEX PRACTICE Put the following entries in the correct order as they pertain to a SOAP note. A. Repositioned patient on right side. Encouraged patient to use patient-controlled analgesia (PCA) device. B. “The pain increases every time I try to turn on my left side.” C. Acute pain related to tissue injury from surgical incision. D. Left lower abdominal surgical incision, 3 inches in length, closed, sutures intact, no drainage. Pain noted on mild palpation.

42. DOCUMENTATION EXERCISE David Page, an 80-year-old man, is admitted to the hospital with a diagnosis of possible pneumonia. He states that he is not feeling well and has a frequent productive cough, which is worse at night. Vital signs are: blood pressure, 150/90 mm Hg; pulse rate, 92 beats/min; respirations, 22 breaths/min. During your initial assessment he coughs violently for 40 to 45 seconds. His lungs have wheezes and rhonchi in both bases and are otherwise clear. He states, “My chest hurts when I cough, and the pain radiates into my arm.”