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Comm./ Docu.

Communication& Documentation

What are some established principles of communication? Sensitivity to others; Promoting and accepting pos./neg. feelings; developing trusting relationships; instilling faith&hope; promoting interpersonal teaching&learning; Providing supportive environment; Allowing spiritual expression
What are some patterns and modes of effective verbal communication? Vocabulary: Denotative& Connotative (knowing language) Pacing: Time& Relevance (knowing when to communicate) Inotation: Clarity& Brevity (tone)
What are some patterns and modes of effective non-verbal communication? general appearance; posture/gait; facial expression/eye contact; gestures; sounds; silence
What are some effective family-centered communication strategies? Communicate as equals; Communicate clearly; Listen with courtesy; Be openminded; Avoid judgement; Communicate openly so informed decisions can be made about family member(s)
What are some communication strategies to use when working effectively with children? Adjust tone; speak on their level; Ask simple target questions (does your tummy hurt? how is your booboo?) Engage them in small talk; Play; Give toys or other distractions; let them initiate first move; Let them explore; be aware of nonverbal cues
What are some general guidelines for developmentally appropriate communication with pediatric clients and their families If the patient is too young to communicate then communicate with the parents, otherwise address both; make sure to match pediatric patients level when speaking to them; be aware of nonverbal cues
What are some communication concerns for elderly clients? Strains in hearing or vision could affect the clients ability to communicate effectively
What are some communication concerns when dealing with infants or children too young to talk? There are language barriers with small children and infants; most communication is done through a series of facial expressions or "cooing"; some parents teach sign language to communicate at young age
What is a communication issue you could run into regardless of a specific age? Due to diversity, patients may struggle with communication if their first language is not english/they speak no english; translators may be required
List examples of nursing diagnoses pertaining to communication Any patients with impaired verbal communication, such as: Those on ventilators/ stroke victims; other diagnoses include: anxiety; social isolation; ineffective coping; compromised family coping; powerlessness; impaired social interaction
Identify mechanisms of group process as a means of achieving goals Small group communication; have similar goals; provide support to one another; group as whole is cohesive& committed; Provides recognition & acceptance of the contributions of each member in the group
What are some effective communication techniques for older patients? Make sure patient is aware your talking; face patient; speak clearly& slowly; check for hearing aids&glasses; use adaptive equipment; choose quiet&well lit environment; allow time for response; be short& too the point; re-teach
What are some health states that contribute to impaired communication Patients on ventilators/ life support; stroke victims; patients in a coma..etc.
Discuss and define SABR SABR is a type of documentation; S- Situation: Whats going on with the patient? B-Background: What is the clinical background of the patient? A-Assessment: What do I think the issue is? R-Reccomendation: What would I recommend be done?
What are some guidelines for effective documentation? Record all facts; Chart only for yourself; Be thorough; Make prompt changes if necessary; Leave no blanks in notes
What are some purposes of the client health care record? Valuable source of data for all members of healthcare; communication; legal documentation; financial billing; education; research; auditing/ monitoring
What are quality guidelines for documentation and reporting? Factual; accurate; complete; current; organized
What is narrative documentation? Story-like format; traditional method of documentation
What is SOAP? Format for progress notes; acronym focuses on subjective/objective data as well as assessment and planning; medical records= origin
What is PIE 2nd progress note method; has nursing origin; focuses on problem/intervention/evaluation; numbered&labeled by problem
What is case management? Method that incorporates interdisciplinary approach to documenting patient care
What is charting by exception? Focuses on documentation deviations from established norms; highlights trends or changes in condition; one assumption made is that ALL standards are met unless otherwise documented
What are some legal guidelines to be considered in charting? Do not erase any info (scratch out errors); Don't make critical comments/document opinions; correct errors promptly; record ALL facts; No blank spaces; Chart for yourself only; If an order was questioned take not clarification was sought;date/time/initial
What are some ways to maintain confidentiality of electronic/ written records? Keep computer screen faced away from anyone who is not the patient; keep password to information system private; be aware of clipboard if writing info manually; Avoid sharing printers/No faxing private records; keep low voice when in discussion
What is the purpose of a shift report "hand-off" Includes basic identifying info about each patient; current appraisal of patient status; any changes in condition; response to therapy; patient's stance in diagnosis&goals; current orders for nurse/physician; summary of newly admitted patients; discharge
What are the advantages of a nursing information system? increases time spent w/ patient; better access to info; enhanced quality of documentation; reduced errors in omission; reduced hospital costs; increased nurse job satisfaction; develops common clinical database
Created by: amandamarie194