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Communication and documentation Flashcards

(20 cards)

1
Q

What is communication?

A

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.

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2
Q

What is the role of nurses in communication?

A

As nurses, we need to have advanced communication skills and be able to adapt them to suit each situation.

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3
Q

Define therapeutic communication.

A

Therapeutic communication involves facilitative communication interventions such as active listening, sharing observations, expressing empathy, and asking relevant questions.

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4
Q

What are the key components of verbal communication?

A
  • Vocabulary
  • Clarity and brevity
  • Timing and relevance
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5
Q

List some non-verbal communication cues.

A
  • Intonation
  • Posture and gait
  • Facial expression
  • Eye contact
  • Gestures
  • Territoriality and personal space
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6
Q

What is the purpose of the health assessment interview?

A

To collect accurate and thorough information on the patient and to build rapport with the patient.

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7
Q

What should a nurse consider when collecting subjective data?

A
  • Empathy
  • Interest in what the person has to say
  • Active listening with open body language
  • Professional behaviour
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8
Q

How should communication change for infants?

A

Communication is primarily with the caregiver, using gentle calm speech when examining the baby.

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9
Q

What are the communication needs of children aged 1-6 years?

A

Communication is with the caregiver, and information can be gathered from the child through play.

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10
Q

What is ISOBAR in the context of nursing?

A

ISOBAR is a structured handover method used to communicate the health care situation of patients.

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11
Q

What does ISOBAR stand for?

A
  • Introduction
  • Situation
  • Observation
  • Background
  • Assessment
  • Recommendation
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12
Q

What is a key guideline for documentation in nursing?

A

If it is not documented, it didn’t happen.

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13
Q

What should a nurse do when they make an error in documentation?

A

Single line through the mistake, write ‘error’ and initial it.

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14
Q

What are common nursing documents designed for communication?

A
  • Inpatient progress notes
  • Admission and discharge forms
  • Care plans
  • Fluid balance charts
  • Vital signs charts
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15
Q

What is the D.A.R. method in charting?

A
  • Data (subjective and objective)
  • Action or nursing intervention
  • Response of patient
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16
Q

True or False: Nurses should leave blank spaces in documentation.

17
Q

Fill in the blank: The health assessment interview is used to collect _______ data.

18
Q

What is the focus of narrative documentation style?

A

It tells the story of the patient, their condition, and nursing interventions.

19
Q

What should documentation include to ensure accountability?

A

Start with date and time, finish with signature, name and title.

20
Q

What is an important communication strategy when interacting with older adults?

A

Establish rapport with respect and be aware they may tire easily.