Communicating with the Health Team (Chapter 4) Day 1

Nursing Assistant Class

Communication

Health team members communicate with each other to give coordinated and effective care.
- Always have good eye contact and speaking clearly for good communication

The Medical Record (Info 1)

The medical record (Chart) is a written or an electronic account of a persons condition and response to treatment and care.
- Its a permanent and legal document

• Policies addressed (records): Who records, when to record, abbreviations, correcting errors, ink color, singing entries

The Medical Record

• Keep an ethical and legal duty of persons information confidential

• Under OBRA, residents or their legal representatives have the right to the information in their medical records or chart

• If asked for chart, report to nurse

Content in a Medical Record

• Admission sheet-contains demographics

• Progress notes-written description of care give

• Flow sheets-the activities of daily living (ADL) flow sheet is used to record a persons ability to perform ADLs. The flow sheet addresses:
  - Hygiene
  - Food and fluids
  - Elimination
  - Rest and Sleep
  - Activities
  - Walking
  - Vital Signs
  - Behaviors exhibited
  - Social Interactions
  
  

Kardex

A type of card file. It summarizes information found in medical record ie: meds, treatments, diagnosis, routine care measures, equipment, and special needs

Resident Care Conferences

• ORBA requires two types of resident care conferences:
  - Interdisciplinary care planning conference
  - Problem focused conference

The Resident has the right to take part in these planning conferences

Reporting and Recording

Reporting is the oral account of care and observations.
Recording (Charting) is the written account of care and observations.
- You report care and observations to the nurse
- Report to the nurse at once whenever there is a change from normal or a change in the persons condition

Medical Terms and Abbreviations

Prefixes, roots, and suffixes
- A prefix is a word element placed before a root
- The root is the word element that contains the basic meaning of the word.
- A suffix is a word element placed after a root
Medical terms are formed by combining word elements.

• Prefix come before roots

• Suffixes always come after roots

  A root can be combined with prefixes, roots, and suffixes

Medical Terminology Examples

Prefixes: Ante -Before, forward, in front , Dys - bad, difficult, abnormal
Root: Angi (o) - vessel , Cyan (o) - blue
Suffix: -algia (pain) - emia (blood condition)

The abdomen is divided into the following regions:

• Right Upper Quadrant (RUQ)

• Left Upper Quadrant (LUQ)

• Right lower quadrant (RLQ)

• Left Lower Quadrant (LLQ)

Directional Terms

Directional terms give the direction of the body part when a person is standing and facing toward.
Anterior (Ventral) - at or toward the front of the body or body part
Distal - the part farthest from the center or from the point of attachment
Lateral - away from the midline; at the side of the body pr body part
Medical - at or near the middle or midline of the body or body part
Posterior (dorsal) - at or toward the back of the body or body part
Proximal - the part nearest to the center or to the point of origin

Telephone Communication

Good communication skills are needed when answering the phone
- Be professional and courteous. Practice good work ethics. Follow the centers policy.

Dealing with Conflict

Conflict is a clash between opposing interest or ideas