221: Communication, Documentation & Reporting

What is communication used for with patients?

For them to express their wants and needs

• relationship is in the center of the fundamental care network and without communcation, you can’t build a relationship

• includes verbal, non-verbal and written

What are 5 ways to communicate

• reading

• speaking

• listening

• writing

• non-verbal signs (upset, ignoring nurse, interested, facial cues)

This includes things such as reading charts, documentations, SBAR, history , plan of care etc.

Documentation is__________

any written or electronically generated information about a client that describes the care or services provided to that client… an essential part of nursing practice

Why do we document?

• documentation asap keeps the information fresh in mind, makes charting accurate, clear and objective

documentation promotes effective communication, safe patient care, continuity of care rather than starting over, record of critical thinking, describes quality of care and standards of practice

How can documentation be used as legal evidence?

It serves as a legal document providing evidence of care

Where do we documment?

• formal charts

• Elec records like connect care

• doctor’s boards

• Kardex

**Doctor’s boards and Kardex are informal à not formal legal forms of documentation

What are the CRNA standards for documentation??

Accountability

communication and safe provision of care

security

What is standard one of CRNA for documentation?

accountability

What is standard two of CRNA for documentation?

communication and safe provision of care

What is standard three of CRNA for documentation?

security

Guidelines for documentation include?

• recording facts

• correcting errors promptly, so instead of deleting something, we strike it out and then sign initials

• avoid generalizations

• chart only for yourself!!!

• Never chart something before it happens

• use only approved abbreviations

For starting documentations, what do we always begin with?

Always begin with date, time (24 hr clock)

For ending documentations, what do we always end with?

end with name and designation (C.J. RN)

What does SOAP stand for?

subjective

objective

assessment

plan

what does PIE stand for?

Problem

Intervention

Evaluation

What does DAR stand for?

Data

Action

Response

What is SBAR used for?

situation background assessment recommendations

• used when we have a concern or sudden change to report to doctor or hand-off

What does SBAR consist of?

•Situation- who is calling, why and situation- or major concern.  Urgency & Hook

•Background- pertinent information, events leading up

•Assessment- what do I think is the problem? Assessment of the situation, what we think is going on

•Recommendation (or request)-what do I recommend- what needs to be done. (could be as simple as asking doctor to re-assess)

What is the health information act (HIA)

Canadian “HIPPA”

• provincial legislation including expectations for the collection, use, disclosure and security of health information

• - protects privacy and confidentiality of individuals and health information

→Requires whoever is performing or works for agency, understand the privacy requirements that apply to practices and we take appropriate measures to safeguard information

How do communication challenges arise ?

sensory deficits —> vision and hearing

cognitive deficits —> dementia & aphasia

Language barriers —> translators aren’t readily available

What are the CRNA standards about social media?

Doesn’t breach confidentiality

• Has no derogatory comments about people they work with or agency they work with

• No comments about patients

• Careful about posting personal views

• Giving information should be evidence based and just don’t post health advice online

• Let people go and look things up for themselves

what are some barriers to good communication?

•Different communication styles

•High level of activity —> like the game of telephone, message gets interrupted

•Frequent interruptions

•Complex healthcare environment —> Encourage asking questions

•Stress

•No standardization in organizing essential information