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Chapter 6

Chapter 6. Communicating With the Health Team. Health team members communicate with each other to give coordinated and effective care. They share information about: What was done for the person What needs to be done for the person The person’s response to treatment. Communication.

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Chapter 6

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  1. Chapter 6 Communicating With the Health Team

  2. Health team members communicate with each other to give coordinated and effective care. • They share information about: • What was done for the person • What needs to be done for the person • The person’s response to treatment

  3. Communication • Communication is the exchange of information. • 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 information in a logical and orderly manner. • Give facts and be specific.

  4. The Medical Record • The medical record (chart, clinical record) is: • A written 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

  5. You have an ethical and legal duty to keep the person’s information confidential. • Under OBRA, residents have the right to the information in their medical records. • These forms relate to your work: • The admission sheet • Progress notes • Activities of daily living (ADL) flow sheet • Other flow sheets • The Kardex is a type of card file. • It summarizes information found in the medical record.

  6. 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.

  7. 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

  8. Anyone who reads your charting should know: • What you observed • What you did • The person’s response

  9. Recording Time (24-hour Clock)

  10. 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.

  11. The abdomen is divided into the following regions: • Right upper quadrant (RUQ) • Left upper quadrant (LUQ) • Right lower quadrant (RLQ) • Left lower quadrant (LLQ)

  12. Directional terms give the direction of the body part when a person is standing and facing forward. • 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

  13. Abbreviations • Abbreviations are shortened forms of words or phrases. • Use only those accepted by the center.

  14. Computers in Health Care • Computer systems collect, send, record, and store information. • 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.

  15. Phone Communications • Good communication skills are needed when answering phones. • Be professional and courteous. • Practice good work ethics. • Follow the center’s policy.

  16. 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.

  17. 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.

  18. 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.

  19. Quality of Life • Health team members must communicate with each other for effective and coordinated care. • False or incomplete information can harm the person. • Resident information is personal and confidential. • Always protect the right to privacy.

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