Communication and documentation Flashcards
(20 cards)
What is communication?
Interpersonal communication involves the capacity to convey thoughts, feelings and attitudes through spoken, written and non-verbal means in order to exchange ideas and construct human meaning.
What is the role of nurses in communication?
As nurses, we need to have advanced communication skills and be able to adapt them to suit each situation.
Define therapeutic communication.
Therapeutic communication involves facilitative communication interventions such as active listening, sharing observations, expressing empathy, and asking relevant questions.
What are the key components of verbal communication?
- Vocabulary
- Clarity and brevity
- Timing and relevance
List some non-verbal communication cues.
- Intonation
- Posture and gait
- Facial expression
- Eye contact
- Gestures
- Territoriality and personal space
What is the purpose of the health assessment interview?
To collect accurate and thorough information on the patient and to build rapport with the patient.
What should a nurse consider when collecting subjective data?
- Empathy
- Interest in what the person has to say
- Active listening with open body language
- Professional behaviour
How should communication change for infants?
Communication is primarily with the caregiver, using gentle calm speech when examining the baby.
What are the communication needs of children aged 1-6 years?
Communication is with the caregiver, and information can be gathered from the child through play.
What is ISOBAR in the context of nursing?
ISOBAR is a structured handover method used to communicate the health care situation of patients.
What does ISOBAR stand for?
- Introduction
- Situation
- Observation
- Background
- Assessment
- Recommendation
What is a key guideline for documentation in nursing?
If it is not documented, it didn’t happen.
What should a nurse do when they make an error in documentation?
Single line through the mistake, write ‘error’ and initial it.
What are common nursing documents designed for communication?
- Inpatient progress notes
- Admission and discharge forms
- Care plans
- Fluid balance charts
- Vital signs charts
What is the D.A.R. method in charting?
- Data (subjective and objective)
- Action or nursing intervention
- Response of patient
True or False: Nurses should leave blank spaces in documentation.
False.
Fill in the blank: The health assessment interview is used to collect _______ data.
[subjective]
What is the focus of narrative documentation style?
It tells the story of the patient, their condition, and nursing interventions.
What should documentation include to ensure accountability?
Start with date and time, finish with signature, name and title.
What is an important communication strategy when interacting with older adults?
Establish rapport with respect and be aware they may tire easily.
