communication and documentation
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114 Terms
a confidential, permanent, legal document
medical record
true or false: only healthcare professionals directly involved in the client’s care should access the client’s record
true
what are some ways that nurses can protect confidentiality
log off computers when finished, do not share passwords, follow HIPAA and facility policies
all patient information is confidential, whether it is
written on paper, spoken aloud, a patient’s name, address, phone number, or other identifying information
the collection of information regarding a patient’s health and care
patient record
what is the most important day-to-day purpose of patient records
communication
the record allows nurses, physicians, therapists, pharmacists, and other members of the healthcare team to know:
what has happened, what was assessed, what treatment was provided, how the patient responded, and what still needs to be done
what kind of orders do the patient records contain that direct patient care
diagnostic and therapeutic orders
documentation helps the team develop, evaluate, and modify the patient’s…
plan of care
what kind of documentation method is this: information is separated to its source or discipline
source-oriented record
what are some examples of sections in a source-oriented record
history and physical, nursing notes, progress notes, lab reports, diagnostic tests
what kind of documentation method is this: information is organized according to the patient’s problems or diagnoses
problem-oriented record
what does a problem-oriented record usually include
database, problem list, plan of care, progress notes
what are SOAP notes used for?
documentation
in SOAP what does S stand for
subjective
in SOAP what does the O stand for
objective
in SOAP what does the A stand for
assessment
in SOAP what does P stand for
plan
what does the “subjective” piece of SOAP include
what the patient reports
what does the “objective” piece of SOAP include
what you observe, assess, or measure
what does the “assessment” piece of SOAP include
interpretation of the subjective and objective findings
what does the “plan” piece of SOAP include
what will be done next
what does the P stand for in PIE charting
problem
what does the I stand for in PIE charting
intervention
what does the E stand for in PIE charting
evaluation
what does the “problem” piece of PIE include
what is wrong
what does the “intervention” piece of PIE include
what did I do
what does the “evaluation” piece of PIE include
did the intervention work
what is DAR used for
focus charting
what is focus charting
it focuses on a particular patient problem, concern, event, or change
what does the D stand for in DAR
data
what does the A stand for in DAR
action
what does the R stand for in DAR
response
a patient’s expected/normal findings are established ahead of time
charting by exception
what happens when you chart by exception
the nurse primarily documents findings that differ from the established norm
documentation follows expected outcomes, timelines, or pathways used to coordinate care
case management model
t/f: to correct documentation errors follow these steps:
preserve the original entry
draw two lines through the incorrect information
mark it as an error and initial it according to policy
record the date/time of the correction
enter the correct information
never use white-out, erase it, or completely cover the original entry
false - only draw one line through the incorrect information
communication without relying only on spoken words
nonverbal communication
what are some examples of nonverbal communication
facial expressions, eye contact, touch, posture, gait, gestures, physical appearance, dress/grooming, sounds, silence
eye contact can communicate what
attention, interest, and respect
does eye contact meant the same thing in every culture
no
touch can communicate what
caring, support, and comfort
what can facial expressions communicate
happiness, fear, anger, confusion, pain, and discomfort
what body posture encourages interaction
an open, relaxed posture
what body posture discourages communication
closed posture, turning away, or appearing rushed
what can be therapeutic and give the patient time to think and express feelings
silence
what are some sounds that can convey information in communication
crying, sighing, moaning, laughing
0-18 inches is considered
intimate
18 inches - 4 feet is considered
personal
4-12 feet is considered
social
12-25 feet is considered
public
what is one of the most standardized communication techniques
SBAR
what does S stand for in SBAR
situation
what does B stand for in SBAR
background
what does A stand for in SBAR
assessment
what does R stand for in SBAR
recommendation
what does the “situation” piece of SBAR include
what is happening right now
what does the “background” piece of SBAR include
what relevant history/background does the healthcare provider need
what does the “assessment” piece of SBAR include
what do you think is occurring based on your assessment
what does the “recommendation” piece of SBAR include
what do you think should happen next
for the following pieces of the SBAR communication technique, sort them into their respective letters
“He was admitted yesterday with pneumonia”
“I recommend you evaluate him now and consider additional oxygen/orders.”
“Respirations are 30/min and oxygen saturation dropped to 86%”
“Mr. Jones suddenly became short of breath”
S - 4
B - 1
A - 3
R - 2
what is another commonly used standardized communication technique other than SBAR
ISBARR
what does I stand for in ISBARR
identity/introduction
what does the S stand for in ISBARR
situation
what does the B stand for in ISBARR
background
what does the A stand for in ISBARR
assessment
what does the first R stand for in ISBARR
recommendation
what does the second R stand for in ISBARR
read back/response
what are the steps for an emergency verbal order
record the order
read it back to verify the accuracy
document the date and time
document the provider who gave the order
document your name/initials according to facility procedure
what is the motivational interviewing acronym
OARS
what does O stand for in OARS
open-ended questions
what does A stand for in OARS
affirmations
what does R stand for in OARS
reflective listening
what does S stand for in OARS
summarizing
what is the interviewing technique that allows many possible responses
open ended
what is an example of an open ended question
“tell me how you’ve been feeling”
what is the interviewing technique that usually produces a short yes/no response
closed
what is an example of a closed question
“are you having pain”
what is the interviewing technique in which the nurse verifies what they think they heard/observed
validating
what is an example of a validating question
“are you saying the pain became worse this morning?”
what is the interviewing technique that makes unclear information clearer
clarifying
what is an example of a clarifying question
“what do you mean when you say you feel strange”
what is the interviewing technique that directs the patient’s thoughts/feelings back toward them
reflecting
what is the interviewing technique that puts events into chronological order
sequencing
what is the interviewing technique that focuses the conversation to obtain additional needed information
directing
expressing yourself in a way that violates the rights of others; can involve anger, accusations, or verbal/physical intimidation
aggressive behavior
clear, honest, confident communication while respecting other people’s rights
assertive behavior
the medium or channel of communication through which the message is sent. it is one of the parts of the communication process
channel
a process that involves a sender/source, message, channel, and receiver
communication
understanding another person’s situation and feelings from their point of view while remaining objective enough to help them
empathy
the response the receiver sends back to the sender showing that the message was received. can be verbal or nonverbal and positive or negative
feedback
the way individual members of a group interact and relate to one another while working toward group goals
group dynamics
anger, aggression, or hostility between nurses. specifically in nursing
horizontal violence
rude, disruptive, intimidating, or undesirable behavior toward another person. this also includes refusing to help or withholding important patient information
incivility
communication between two or more people for the purpose of exchanging messages
interpersonal communication
communication with yourself, also called self-talk
intrapersonal communication
abusive words or actions between peers. examples include gossiping, excluding information, threats of harm, or actual harm
lateral violence
the verbal or nonverbal information the sender communicates and intends the receiver to understand
message
anything that distorts a message or interferes with communication. examples are environmental factors such as a TV or personal factors such as pain or discomfort
noise
a caring professional relationship between the nurse and patient based on mutual respect, with the focus on promoting or restoring the patient’s health and well-being
nurse-patient relationship