Unit 2: Healthcare Communication and Medical Documentation

What is communication in healthcare?

A clinical skill because it can affect patient safety, participation, trust, and whether the patient understand what to do.

What does verbal commutation include?

Word choice, volume, tone, and pace.

What does nonverbal communication include?

Eye contact, personal space, body language, gestures, facial expressions, posture, and active listening.

What is the first step in communicating with a patient?

Introduce yourself.

What is the second step in communicating with a patient?

Explain the procedure.

What is the third step in communicating with a patient?

Ask about the patient's condition.

What is the fourth step in communicating with a patient?

Check that the patient is positioned safely and comfortably.

How would you talk about/to patients with disabilities or conditions?

Use person-first language when preferred, and ask each person what they would like to be called.

What rules should you follow when getting an interpreter?

Speak directly to the patient, get a qualified interpreter, and avoid using idioms.

How would you communicate with a patient who has hearing loss?

Face the patient, reduce noise, and confirm understanding.

How would you communicate with a patient who has visual changes?

Introduce yourself, describe obstacles, and offer large print.

How would you communicate with a patient who has memory or attention difficulty?

Use short, concrete direction, give one step at a time.

How would you communicate with a patient who has anxiety or fear?

Use a calm tone, validate feelings, offer choices.

How would you communicate with a patient who has limited speech or movement?

Allow time and ask which communication method works best.

Why is it important to explain a treatment before beginning it?

To make sure the patient understands the treatment and has the right to deny or adapt treatment to suit their beliefs.

A patient says, “I’m scared I will never walk again.” How would you respond?

We will do our best to work towards that goal or find another solution that works for you.

A patient’s family member keeps answering questions for them. How would you respond?

Talk to the privately and talk to the patients about stepping back a bit and allowing their child to speak.

What are communication adaptations that could help a patient with memory or attention difficulty?

Giving short directions, repeating calmly, reducing directions, and using written steps/routine cues.

What are etiquette guidelines for interacting with a person who uses a wheelchair, walker, cane, prosthesis, or service animal?

Ask before helping/moving their equipment, not touching their service animal, and speak directly to them, not squatting down.

A patient says they are uncomfortable with an exercise because of their beliefs. How should you respond?

Ask the patient what they feel comfortable with and adapt the exercise to fit their beliefs.

A patient who uses a wheelchair is seated while you need to speak with them. How should you respond?

Speak directly to the patient, not leaning or squatting to talk to them.

You are speaking with a patient whose first language is different from yours and they need help understanding instructions. What should you do?

Get a qualified interpreter and speak directly to the patient not the interpreter, and avoid idioms.

What does plain language do?

Helps the patient understand information about care and activities.

What is a prefix?

At the beginning of the word that can change or add meaning.

What is a root?

Contains the core meaning, often a body part or function.

What is a suffix?

At the end of a term and often describes a process or specialty.

What does the prefix hyper- mean?

High/excessive.

What does the prefix hypo- mean?

Low/below normal.

What does the prefix dys- mean?

Difficult, abnormal, or painful.

What does the suffix -itis mean?

Inflammation.

What does the suffix -ectomy mean?

Surgical removal.

What does prone mean?

Laying on the stomach, face down.

What does supine mean?

Laying on the back, face up.

What does UE mean?

Upper extremity.

What does LE mean?

Lower extremity.

What does ROM mean?

Range of Motion.

What does PRN mean?

As need.

What does hypertonic mean?

Excessively high muscle tone, tighter/tenser muscles that allow for less movement.

What does hypotonic mean?

Excessively low muscle tone, loser muscles that allow for more movement/flexibility.

What does inflammation mean?

Body response that may include swelling, warmth, redness, or pain.

What does S in SOAP stand for?

Subjective.

What does the O in SOAP stand for?

Objective.

What does the A in SOAP stand for?

Assessment.

What does the P in SOAP stand for?

Plan.

What goes in the subjective section.

What the patient feels, 0-10 pain level, any other pain felt in the body.

What goes in the objective section.

Measurable variables, amount of reps/distance walked to.

What goes in the assessment section?

Findings from the session, patient status, responses, or progress.

Why do healthcare workers need to know medical terminology?

To specify information when talking to other healthcare workers.

Why do healthcare workers need to know plain language?

To help patients understand their care and plan instructions.

What goes in the plan section?

Next steps for recovery and any treatment need to do at home.

What does this mean in plain language: “Patient performed 6 supine UE raises.”

The patient did six arm raises while laying on their back.