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Chapter 4Communicating With the Health TeamChapter 4Communicating With the Health Team

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Health team members communicate with eachother to give coordinated and effective care.Health team members communicate with eachother to give coordinated and effective care.

•They share information about:•They share information about:

What was done for the personWhat was done for the person

What needs to be done for the personWhat needs to be done for the person

The person’s response to treatmentThe person’s response to treatment

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COMMUNICATIONCOMMUNICATION

Communication is the exchange of information.Communication is the exchange of information.

For good communication:For good communication:

•Use words that mean the same thing to you and thereceiver of the message.•Use words that mean the same thing to you and thereceiver of the message.

•Use familiar words.•Use familiar words.

•Be brief and concise.•Be brief and concise.

•Give information in a logical and orderly manner.•Give information in a logical and orderly manner.

•Give facts and be specific.•Give facts and be specific.

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THE MEDICAL RECORDTHE MEDICAL RECORD

The medical record (chart, clinical record) is:The medical record (chart, clinical record) is:

•A written account of a person’s condition and response totreatment and care•A written account of a person’s condition and response totreatment and care

•A permanent, legal document•A permanent, legal document

Nursing center policies about medical records andwho can see them address:Nursing center policies about medical records andwho can see them address:

•Who records•Who records

•When to record•When to record

•Abbreviations•Abbreviations

•Correcting errors•Correcting errors

•Ink color•Ink color

•Signing entries•Signing entries

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You have an ethical and legal duty to keep theperson’s information confidential.You have an ethical and legal duty to keep theperson’s information confidential.

Under OBRA, residents have the right to theinformation in their medical records.Under OBRA, residents have the right to theinformation in their medical records.

These forms relate to your work:These forms relate to your work:

•The admission sheet•The admission sheet

•Progress notes•Progress notes

•Activities-of-daily-living (ADL) flow sheet•Activities-of-daily-living (ADL) flow sheet

•Other flow sheets•Other flow sheets

The Kardex is a type of card file.The Kardex is a type of card file.

•It summarizes information found in the medical record.•It summarizes information found in the medical record.

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RESIDENT CARE CONFERENCESRESIDENT CARE CONFERENCES

OBRA requires two types of resident careconferences:OBRA requires two types of resident careconferences:

•Interdisciplinary care planning (IDCP) conference•Interdisciplinary care planning (IDCP) conference

•Problem-focused conference•Problem-focused conference

The person has the right to take part in theseplanning conferences.The person has the right to take part in theseplanning conferences.

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REPORTING AND RECORDINGREPORTING AND RECORDING

Reporting is the oral account of care andobservations.Reporting is the oral account of care andobservations.

Recording (charting) is the written account of careand observations.Recording (charting) is the written account of careand observations.

During end-of-shift report, information is sharedabout:During end-of-shift report, information is sharedabout:

•The care given•The care given

•The care that must be given•The care that must be given

•The person’s condition•The person’s condition

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Anyone who reads your charting should know:Anyone who reads your charting should know:

•What you observed•What you observed

•What you did•What you did

•The person’s response•The person’s response

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Recording Time (24 hr. Clock)Recording Time (24 hr. Clock)

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MEDICAL TERMINOLOGYMEDICAL TERMINOLOGY

Prefixes, roots, and suffixesPrefixes, roots, and suffixes

•A prefix is a word element placed before a root.•A prefix is a word element placed before a root.

•The root is the word element that contains the basicmeaning of the word.•The root is the word element that contains the basicmeaning of the word.

•A suffix is a word element placed after a root.•A suffix is a word element placed after a root.

Medical terms are formed by combining wordelements.Medical terms are formed by combining wordelements.

•Prefixes always come before roots.•Prefixes always come before roots.

•Suffixes always come after roots.•Suffixes always come after roots.

•A root can be combined with prefixes, roots, and suffixes.•A root can be combined with prefixes, roots, and suffixes.

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The abdomen is divided into the following regions:The abdomen is divided into the following regions:

•Right upper quadrant (RUQ)•Right upper quadrant (RUQ)

•Left upper quadrant (LUQ)•Left upper quadrant (LUQ)

•Right lower quadrant (RLQ)•Right lower quadrant (RLQ)

•Left lower quadrant (LLQ)•Left lower quadrant (LLQ)

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Directional terms give the direction of the bodypart when a person is standing and facing forward.Directional terms give the direction of the bodypart when a person is standing and facing forward.

•Anterior (ventral)—at or toward the front of the body orbody part•Anterior (ventral)—at or toward the front of the body orbody part

•Distal—the part farthest from the center or from the pointof attachment•Distal—the part farthest from the center or from the pointof attachment

•Lateral—away from the midline; at the side of the body orbody part•Lateral—away from the midline; at the side of the body orbody part

•Medial—at or near the middle or midline of the body orbody part•Medial—at or near the middle or midline of the body orbody part

•Posterior (dorsal)—at or toward the back of the body orbody part•Posterior (dorsal)—at or toward the back of the body orbody part

•Proximal—the part nearest to the center or to the point oforigin•Proximal—the part nearest to the center or to the point oforigin

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ABBREVIATIONSABBREVIATIONS

Abbreviations are shortened forms of words orphrases.Abbreviations are shortened forms of words orphrases.

•Use only those accepted by the center.•Use only those accepted by the center.

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COMPUTERS IN HEALTH CARECOMPUTERS IN HEALTH CARE

Computer systems collect, send, record, and storeinformation.Computer systems collect, send, record, and storeinformation.

Computers do the following:Computers do the following:

•They save time.•They save time.

•They increase quality care and safety.•They increase quality care and safety.

•Fewer errors are made in recording.•Fewer errors are made in recording.

•Records are more complete.•Records are more complete.

•Staff is more efficient.•Staff is more efficient.

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PHONE COMMUNICATIONSPHONE COMMUNICATIONS

Good communication skills are needed whenanswering phones.Good communication skills are needed whenanswering phones.

•Be professional and courteous.•Be professional and courteous.

•Practice good work ethics.•Practice good work ethics.

•Follow the center’s policy.•Follow the center’s policy.

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DEALING WITH CONFLICTDEALING WITH CONFLICT

If problems are not worked out, the following canoccur:If problems are not worked out, the following canoccur:

•Unkind words or actions occur.•Unkind words or actions occur.

•The work setting becomes unpleasant.•The work setting becomes unpleasant.

•Care is affected.•Care is affected.

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The problem-solving process involves these steps:The problem-solving process involves these steps:

•Step 1: Define the problem.•Step 1: Define the problem.

•Step 2: Collect information.•Step 2: Collect information.

The information must be about the problem.The information must be about the problem.

•Step 3: Identify possible solutions.•Step 3: Identify possible solutions.

•Step 4: Select the best solution.•Step 4: Select the best solution.

•Step 5: Carry out the solution.•Step 5: Carry out the solution.

•Step 6: Evaluate the results.•Step 6: Evaluate the results.

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These guidelines can help you deal with conflict:These guidelines can help you deal with conflict:

•Ask your supervisor for some time to talk privately.•Ask your supervisor for some time to talk privately.

•Approach the person with whom you have the conflict.•Approach the person with whom you have the conflict.

•Agree on a time and place to talk.•Agree on a time and place to talk.

•Talk in a private setting.•Talk in a private setting.

•Explain the problem.•Explain the problem.

•Listen to the person.•Listen to the person.

•Identify ways to solve the problem.•Identify ways to solve the problem.

•Set a date and time to review the matter.•Set a date and time to review the matter.

•Thank the person for meeting with you.•Thank the person for meeting with you.

•Carry out the solution.•Carry out the solution.

•Review the matter as scheduled.•Review the matter as scheduled.

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QUALITY OF LIFEQUALITY OF LIFE

Health team members must communicate witheach other for effective and coordinated care.Health team members must communicate witheach other for effective and coordinated care.

False or incomplete information can harm theperson.False or incomplete information can harm theperson.

Resident information is personal and confidential.Resident information is personal and confidential.

•Always protect the right to privacy.•Always protect the right to privacy.