ULO 6- Apply Sound Written and Communication Skills Flashcards

1
Q

Define: Contemporaneous Documentation

A

you are documenting as and when you are giving care. Need to document every time you see the woman, do something for her

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2
Q

Explain: Principles of documentation

A

is:

  • contemporaneous
  • comprehensive
  • logical
  • legible and clear
  • concise and accurate
  • identifies author and designation
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3
Q

Explain: Critical writing

A
  • uses comparison
  • provides evidence for points made
  • consider strengths and weaknesses
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4
Q

Explain: women-centred care and communication

A

omen want to make their own decisions about their pregnancy and birth experience, and strongly prefer a woman-centred approach to maternity care.

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5
Q

Communication among Professionals involved what key components

A
  • mutual support and affirmation that the partnership is working well
  • sharing accurate and appropriate information
  • communication process must include the woman and her community
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6
Q

What are the NSW Health Mandatory Requirements for documentation

A
  • Accurate description of each patient and client’s contact with a health professional
  • A health care record is available for every patient
  • Identification that must appear of every page of the health care record
  • Unique identifier (medical record number, unique patient identifier)
  • Patients family name and given name
  • Date of birth (or gestational age)
  • Sex (excluding ObstetriX records)
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7
Q

Documentation

Define: Addendum

A

if entry has forgotten additional detail it must be written under “addendum”
- include the date/time of the omitted event and the date/time of addendum

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8
Q

Documentation

Define: Written in error

A

must be used when an error has been made

  • Draw a line through incorrect area/mistake
  • Print name , sign, designation and date/time of correction
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9
Q

Define: Communication

A

a verbal or written message which employs a common system of signs, symbols or behaviour to exchange information

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10
Q

What factors can influence people’s communication

A

Culture
Language
Noise
Level of education

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