GERIA - WEEK 10 (COMMUNICATION & DOCUMENTATION)

Communication

is the cohesive force in every human culture and the dominant influence in the personal life of every one of us

Brain

has a major role in attending to new information, making sense of and organizing information, and deciding on a response.

Information sharing

- Help older people make informed decisions by sharing information in the way they prefer writing or demonstrating something can be helpful.

- Avoid sharing too much, too quick.

- Unfamiliar situations can be overwhelming, so slow down and allow people time to process the information.

- Verbal communication - involves sending and receiving messages by means of Words

Paralinguistic cues (i.e., tone, pitch and volume of voice)

Approximately 38% of communication is transmitted by?

Body cues

Approximately 55% of communication is transmitted by?

Actual words

Approximately 7% of communication is transmitted by?

nonverbal

Approximately 93% of communication is transmitted by?

Therapeutic communication

a conscious and deliberate process used to gather Information related to a patient' s overall health status (physical, psychosocial, spiritual, etc.) And to respond with verbal and nonverbal.

Documentation

tells the story of each patient's journey throughout the entirety of each episode of care

Tip #1

Remember that any reviewer of a patient record does not

have the depth of knowledge that is gained from providing care

Tip #2

The contents of the documentation should convey

to any reader such as your manager, a state or accreditation surveyor, or a payer

Tip #3

Document both medical necessity and homebound and support other coverage criteria in your documentation

Tip #4

Look at the documentation objectively.

Tip #5

Make sure calls and other communication across team

members and the physician are documented

Tip #6

Are the patient's areas of risk for hospitalization noted and observed? Are the interventions to prevent this re-occurence documented?

Tip #7

Does each visit by a clinician include the elements of

assessment, care planning, interventions, actions and

continued evaluation?

Tip #8

Documentation should include patient and family caregiver education, their responses to and demonstration of the education provided, as well as

results of the education

Tip #9

The care entries and overall information need to reflect

the level of care expected by healthcare consumers

caregivers, and their families.

Tip #10

clinical documentation should demonstrate compliance

with regulatory, licensure, and quality standards

Confidentiality

refers to the duty to protect privileged information and to share entrusted information responsibly

Confidentiality

It stems from the notion that a person's wishes, decisions, and personal information should be treated with respect

Confidentiality

The duty of confidentiality can apply to individuals,

organizations, and institutions

Privacy

refers to the right to be free from interference

Privacy

is supposed to enable individuals to exert control over their own lives, which includes deciding who should have access to personal information, and when and how this information will be disclosed.

Article I, Section 23

In Florida, the right of privacy is discussed within the state's constitution in what article?

Fourteenth Amendment

the U.S. Constitution guarantees a right to privacy, the legal basis for the right to privacy typically stems from the?

HIPAA

Health Insurance Portability and Accountability Act of 1996

HIPAA

is a federal law that was created in part to protect

information contained within the medical records of patients