Tut 1 communication W2 Flashcards
(48 cards)
what is the goal of communication
- Exchange of health-related information
- Promotion of a therapeutic relationship
- Development of collaboration with other health professional
what is the process of communication
- Non-verbal
- Structured – eg health education
- Unstructured – being present
- Documentation
ISBAR method for written communication
- Identification – who am I, which patient am I talking about
- Situation – what is the key information
- Background – what is the pertinent information relevant to this patient
- Assessment – what are my findings from my assessment
- Recommendation – what do I recommend should happen now
what is the purpose of documentation
- To create a medical record (permanent, legal document)
- Purpose of record
- Communication
- Record patient assessment and progress
- Legal defence
- Financial reimbursement
- Education, Research, Audit
what do you need to document?
• Vital signs
• Any occurrences, particularly deterioration and
improvements
• When we call for the patient to be reviewed
• When a patient is transferred to the care of another health professional
how to document
• Continuation paper:
• Ongoing patient state, entries each shift. Start each entry
with heading: ‘Nursing’
• Write clearly in black or blue
• Always sign and date
• ‘If it is not documented then it was not done’
• Observation charts: vital signs, fluid balance, pre-op charts, pain charts, stool charts
Epi-
on; upon; over
Eso-
inward
Eu-
normal, good
Ex-
outside, outward
Exo-
outside;outward
Extra-
outside of; beyond
Hemi-
half
Hyper
above;excessive
hypo-
below;incomplete;deficient
-itis
inflammation of a specified organ
-ectomy
surgical removal of something specified
-otomy
to make an incision or cut into
-gram
record; x-ray film
- graph
instrument used to record
-graphy
process of recording; xray filming
aden/o
gland
amni/o
aminion (sac of fluid surrounding the embryo)
angi/o
vessel
