Basic Healthcare Practices & Medical Scribe Learning Resource

I. COMMUNICATIONS

  • All members of the healthcare team must communicate clearly and therapeutically with patients.
    • Communication must be organized and logical.
    • Elements such as what you say, timing, and nonverbal cues affect the relationship with the patient.

Reasons for Communication

  • To meet our needs
  • To develop relationships
  • To fulfill social obligations
  • To influence others
  • To exchange information

Communication Statistics

  • It is estimated that people spend 50-80% of their time communicating in the workplace.
  • Patient feelings towards healthcare significantly stem from communication with healthcare workers.
  • Poor communication is cited as the underlying cause of approximately 70% of malpractice litigation.

Factors Influencing Communication

Basic Components of Communication

  • Sender: Initiates the communication cycle by encoding a message and formulating a clear thought to send.
  • Message: The content that needs to be communicated.
  • Receiver: The person who receives the message from the sender.
  • Feedback: The response from the receiver back to the sender, confirming or clarifying the interpretation of the message. Feedback can be verbal or non-verbal.

Modes of Communication

  • Speaking
  • Listening
  • Gestures or body language
  • Writing

Key Points for Successful Communication

  • Congruency: Verbal and non-verbal messages must be consistent.
  • Clustering: Grouping of gestures, facial expressions, and postures into coherent nonverbal statements.

Participants in Communication

  • Perceptions: Individual uniqueness that affects interpretation, including values, personality traits, and life experiences.
  • Sociocultural background: Family, ethnic, cultural, and community influences that affect sending and receiving messages.
  • Roles and Relationships: The dynamic between roles like student-instructor, parent-child, or provider-patient affects communication choices.
  • Emotions: Feelings such as fear, joy, or anger can impact message reception.
  • Knowledge/Abilities: Influences how one chooses words and interprets messages.
  • Self-Esteem: Affects openness and honesty in communication; low self-esteem can lead to incongruence.

Environmental Factors in Communication

  • Personal Space: Preferred distances for interaction:
    1. Intimate: Physical contact to 1.5 feet
    2. Personal: 1.5 to 4 feet
    3. Social: 4 to 12 feet
    4. Public: 12 feet and beyond
  • Territoriality: The space individuals claim as their own; showing respect is crucial (ask for permission).
  • External Noise: Distractions in the environment affecting attention.
  • Internal Noise: Personal thoughts and feelings that detract from communication.

Message Factors

  • Context: The situation that gives meaning to words.
  • Vocabulary: Professionals must tailor their language for colleagues vs. patients.
  • Pacing: Adjusting speech pace according to patient needs, taking into account their circumstances.
  • Questions: Favor open-ended questions to solicit more information from patients.
  • Directions: Provide step-by-step directions to avoid overwhelming patients.
  • Feedback: Essential for verifying message receipt.
  • Nonverbal Cues: Includes touch, eye contact, facial expressions, posture, gait, and gestures.
  • Dress/Grooming: Statements about oneself and how one perceives others.
  • Paralanguage: Sounds and speech cues that indicate listening (e.g., "uh-huh").
  • Silence: Can convey support or understanding.

Barriers to Effective Communication

  • Language Deficits: Identify primary language and interpreter needs.
  • Sensory Deficits: Consider how impairments in hearing, sight, or touch can impact communication.
  • Cognitive Impairments: Affect language use and understanding, e.g., Alzheimer’s, head injuries.
  • Unconscious Patients: May still hear but have limited feedback; respect their privacy.
  • Structural Deficits: Physical conditions affecting speech and clarity.
  • Paralysis: May hinder speech or writing; alternative methods like communication boards can assist.

Therapeutic Communications

  • Requires well-defined professional skills.
  • Involves a skilled person interacting with a patient in need (not judgmental).
  • Encourages patients to freely express feelings and emotions; displays empathy and respect.
  • Requires careful monitoring of body language, ensuring a supportive environment.

Non-Therapeutic Communications

  • Unwarranted Reassurances: Clichés may block patient from expressing fears.
    • Example: "Everything will be fine."
  • Stereotypical Comments: Invalid generalizations about groups of individuals.
  • Probing Questions: Personal queries that may invade privacy.
  • Common Advice: Undermines patient agency in decision-making.
  • Judgmental Responses: Opinions that impose the healthcare provider's values.
  • Agreeing/Disagreeing: This can shut down patient dialogue.
  • Rejections: Stopping discussions on certain topics can make patients feel dismissed.
  • Failure to Listen: Hinders effective communication.

Listening Skills

  • Active Listening: Engaging with the speaker by focusing on verbal and non-verbal cues.
  • Good Listening Skills include:
    • Avoiding distractions
    • Maintaining eye contact
    • Not interrupting
    • Asking clarifying questions
  • Open-Ended Questions: Require more than yes/no answers.
  • Closed-Ended Questions: Answered with a yes or no, useful for specific information.
  • Empathy vs Sympathy: Understanding the patient's feelings vs feeling sorry for them.
  • Reflecting, Restating, Clarification: Confirm understanding by mirroring the patient’s message or requesting more information for clarity.

Reasons for Poor Listening

  • Prejudice: Dismissing information from perceived unworthy speakers.
  • Jumping to Conclusions: Forming opinions before comprehending the full message.
  • Making Assumptions: Presuming to know what the speaker will say.
  • Inattention: Speaking slower than thinking leads to a focus on formulating responses over listening.
  • Selective Listening: Only processing parts of the conversation that seem relevant.
  • Excessive Talking: Reduces listening opportunities for the listener.
  • Lack of Empathy: Difficulty in understanding the speaker’s perspective.
  • Fear: Fear of negative information can lead to evasion of listening.

Tips for Improving Listening Skills

  • Practice active listening by reducing talking time.
  • Pay attention to both words and feelings.
  • Adopt an appropriate listening posture.

Types of Conversations in Healthcare Settings

  • Social Conversations: Create a relaxed atmosphere without personal disclosures from the provider.
  • Interviews: Obtaining necessary information from the patient for care.
  • Teaching: Educating patients about health-related topics.
  • Problem Solving: Addressing patient needs once you understand those needs.

General Guidelines for Patient Conversations

  • Approach patients with courtesy and friendliness.
  • Identify patients and explain procedures clearly.
  • Use language appropriate to the patient's understanding.
  • Maintain comfort and safety in the patient’s environment.
  • Facilitate patient questions before leaving.

II. MEDICAL DOCUMENTATION

A. Definition

  • Medical Record: Collection of data recorded when a patient seeks medical treatment.

Purposes of Medical Records

  • Required for licensing authorities.
  • Provide documentation for ongoing patient care from birth to death.
  • Serve as legal documents in litigation.
  • Offer data for educational and research purposes.

Key Questions Addressed by Medical Records

  • Who, what, when, where, why, and how of patient treatment.

Five C’s of Charting

  1. Concise
  2. Complete (and objective)
  3. Clear (and legibly written)
  4. Correct
  5. Chronologically ordered

B. Ownership

  • Physical Documentation: Owned by the healthcare provider or facility.
  • Information: Owned by the patient; they may request copies subject to laws and fees.

C. Purpose/Use

  • Documenting patient's diagnosis, treatment, progress, and establishing communication among workers.
  • Business purposes, including insurance, statistics, and education.

D. HITECH Act and Meaningful Use (MU)

  • HITECH: Enacted to promote health information technology.

Main Components of Meaningful Use

  • Use certified Electronic Health Record (EHR) technology to improve quality of care.
  • Reward measures focusing on care coordination, reducing disparities, patient engagement, public health enhancement, and ensuring data privacy and security.

E. Electronic Medical Record (EMR)

  • Digital records stored for clinician access and improving communication.

Core Requirements for Meaningful Use

  1. Use computerized orders for medications.
  2. Implement drug checks.
  3. Maintain comprehensive lists of medications and allergies.
  4. Record and chart vital signs, demographics, and smoking status.
  5. Provide patients with copies of their health information.

F. Organization of Medical Records

  • Source Orientated: Similar forms grouped, reverse chronological order during hospitalization.
  • Problem Orientated: Each problem assigned a number for reference across documentation.

G. Documentation Criteria

  • Key points when documenting:
    • Patient’s name on every page.
    • Date and time for all entries.
    • Professional signature on all entries.
    • Make accurate, clear, detailed, and logical entries; observe objectivity.

H. Correction of Errors

  • Correct errors by striking through incorrect entries, dating corrections, and never obliterating the erroneous entry completely.

I. Abbreviations

  • Extensive lists of accepted medical abbreviations should be adhered to, typically provided by institutions

J. Confidentiality and Release of Information

  • Understanding of confidentiality, HIPAA compliance, and policies for patient information release.

HIPAA Highlights

  • Covers protected health information (PHI), stipulating conditions for disclosure even under various circumstances (treatment, payment, health care operations).

K. The Medical Record

  • Credited to staying within the healthcare office without leaving its integrated settings.
  • Procedures in place for managing inactive and closed medical records appropriately.

L. Retention Schedule

  • Hospitals retain medical records indefinitely if concerned with liability; AMA suggests 10 years.

M. Health History Definition

  • Information pertaining to the patient for accurate treatment decision-making.

Components of Patient History

  1. Introduction Data with personal information.
  2. Chief Complaint (CC): The purpose of visit, phrased in the patient's own words.
  3. Present Illness (PI): Detailed account of the chief complaint.
  4. Past History (PH): Previous medical and surgical history.
  5. Family History (FH): Health conditions of relatives.
  6. Review of Systems (ROS): Evaluation of each system for missed conditions.
  7. Personal/Sociocultural History (PSH): Information about lifestyle and background impacting health.

Example Patient Documentation

  • Document insights based on hypothetical patient interviews, assessments, and plans.

III. MEDICAL SCRIBE

A. Who are Scribes

  • Integral members of the medical team working across multiple settings (clinics, hospitals).

B. Role of a Scribe

  • Core role in documenting patient encounters alongside healthcare professionals, noting the scope varies.

C. Responsibilities

  1. Documentation of medical records.
  2. Ensuring smooth patient flow within settings.

D. Necessary Knowledge for Scribes

  • Emphasis on electronic health records, HIPAA guidelines, medical terminology, anatomy, writing methodologies, and billing principles.

E. Structure of the Primary Care Clinic

  • Functional Staff:
    • Registration staff, CMAs, providers, NPs, PAs, physicians, and various specialists outlined.

F. Types of Clinical Visits

  • Distinction between new patient appointments, annual physicals, well child checks, and various specialty consultations, including preventive care specifics.

IV. HEALTHCARE NAVIGATOR

A. Background

  • The role emerged to alleviate obstacles in achieving optimal healthcare access and efficiency.

B. Definition & Importance

  • Navigators guide patients through healthcare barriers ensuring timely access to care while promoting culturally competent support.

C. Goals of the Navigator

  • Expedite treatments and diagnosis while ensuring patients attend follow-ups for comprehensive care continuity.

D. Impact of Navigation Roles

  • Enhances patient satisfaction by addressing healthcare barriers effectively.

V. INFECTION CONTROL

A. Principles of Infection Control

  • Medical Asepsis: Reducing microorganism levels to prevent transmission, establishing clear goals for practice.

B. Conditions Favoring Pathogens

  • Factors like moisture, nutrients, temperature, and darkness that support pathogen growth explored.

C. Infection Cycle Overview

  • Describes the need for understanding reservoir hosts, transmission vehicles, and susceptibility.

D. Healthcare Infections

  • Emphasis on preventing nosocomial infections among patients and staff.

E. Common Communicable Diseases

  • Lists major diseases, transmission methods outlined.

F. Infection Control Techniques

  • Hygiene practices and guidelines for maintaining sanitary conditions highlighted, including personal protective equipment protocols.