Communication& Documentation
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| 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
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| 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)
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| What are some patterns and modes of effective non-verbal communication? | general appearance; posture/gait; facial expression/eye contact; gestures; sounds; silence
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| 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)
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| 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
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| 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
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| What are some communication concerns for elderly clients? | Strains in hearing or vision could affect the clients ability to communicate effectively
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| 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
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| 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
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| 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
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| 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
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| 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
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| What are some health states that contribute to impaired communication | Patients on ventilators/ life support; stroke victims; patients in a coma..etc.
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| 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?
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| 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
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| 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
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| What are quality guidelines for documentation and reporting? | Factual; accurate; complete; current; organized
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| What is narrative documentation? | Story-like format; traditional method of documentation
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| What is SOAP? | Format for progress notes; acronym focuses on subjective/objective data as well as assessment and planning; medical records= origin
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| What is PIE | 2nd progress note method; has nursing origin; focuses on problem/intervention/evaluation; numbered&labeled by problem
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| What is case management? | Method that incorporates interdisciplinary approach to documenting patient care
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| 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
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| 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
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| 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
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| 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
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| 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
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