Interprofessional Communication Within the Healthcare Team - Documenting and Reporting Flashcards
Takes place through the patient’s record or chart and reports.
Communication
A confidential, permanent legal document of information relevant to a patient’s health care. Information about the patient’s health care is recorded after each contact with the patient.
Record or chart
All health records contain the following information:
- Patient i___ and demographic data
- Informed consent for treatment and procedures
- Advance directives
- Admission nursing ___
- Nursing ___ or problems and the nursing or interdisciplinary care plan
- Record of nursing care treatment and ___
- ___ history
- Medical diagnosis
- Therapeutic orders
- Progress notes for various health care providers
- Reports of physical examinations
- Reports of diagnostic studies
- Record of patient and family education
- Summary of operative procedures
- Discharge plan and summary
identification
history
diagnoses
evaluation
Medical
Are oral, written, or audiotaped exchanges of information between caregivers.
Reports
Commonly compiled by nurses include change-of-shift reports, telephone reports, transfer reports, and in___ or occurrence reports.
in-cident
A physician or nurse practitioner may call a nursing unit to receive a ___ report on a patient’s condition and progress. A laboratory submits a ___ report about the results of diagnostic tests.
verbal / written
Form of discussion whereby one professional caregiver gives formal advice about the care of a patient to another caregiver. For example, a nurse caring for a patient with a chronic wound may need a consultation with a wound care specialist.
Consultations
An arrangement for services by another care provider.
Referrals
Consultations and conferences must be d___ in a patient’s permanent record so that all caregivers can plan care accordingly.
documented
Discussions through which team members communicate information.
Conferences
