COMMUNICATION AND COLLABORATION

COMMUNICATION AND COLLABORATION

Objectives

• Review concepts of communication and collaboration

• Identify documentation standards and principles

• Differentiate between electronic medical record (EMR) and electronic health record (EHR)

• Discuss the role of nurse in documentation

• Describe incident reports and hand-off reports

• Explain health literacy

• Recognize factors affecting health literacy and the nurse’s role in ensuring patient teaching

Communication and Collaboration: What Do We Know?

Health Care Documentation

• Definition: Any written or electronically generated information about a patient that describes the patient, the patient’s health, and the care/services provided.

• Purpose: Facilitation of information flow to support the continuity, quality, and safety of care.

• Goal: To describe the FACTS clearly and concisely to improve interdisciplinary communication.

Documentation Standards and Principles

• Established by healthcare organization: Must be in agreement with the Joint Commission standards.

• Accessibility: Accessible only by authorized personnel.

• General Principles:

  • Completeness and Legibility: Documentation must be clear and readable.

  • Reason for Patient Encounter: Document reasons for patient visitation.

  • Content to Include:

  • Assessments

  • Diagnoses

  • Plans of care

  • Patient progress

  • Any changes in diagnosis/treatment

  • Reimbursement Necessity: Necessary for reimbursement by Diagnosis-Related Groups (DRGs).

The Medical Record

• Content: Contains comprehensive information about:

  • Patient health care encounters

  • Demographic data

  • Administrative data

  • Clinical data

• Functions:

  • Communication Tool: Facilitates communication among healthcare personnel.

  • Single Data Access Point: Provides a unified resource for staff.

  • Legal Document: Must meet guidelines as a legal document.

  • Continuity of Care: Promotes ongoing patient care.

  • Clinical Data Archive: Serves as an archive for patient data.

  • Research Tool: Enables research and analysis through data access.

Electronic Health Records (EHR) and Electronic Medical Records (EMR)

• Electronic Medical Record (EMR):

  • Definition: A record of one episode of care.

• Electronic Health Record (EHR):

  • Definition: Longitudinal record of health information over time.

• Advantages of EHR:

  • NOT specified in transcript.

• Disadvantages of EHR:

  • NOT specified in transcript.

Nursing Documentation

• Importance: Record of nursing care and the contribution to patient outcomes.

• Characteristics:

  • Must be clear, concise, complete, and objective/factual (proper spelling and grammar required).

• Content to Include:

  • Assessments

  • Interventions

  • Condition changes

  • Evaluations

• Guidance: Guided by the 5 steps of the nursing process.

• Function: Essential piece of effective communication among all healthcare providers.

• Standards: Demonstrates that all professional/legal standards of care are met.

• Financial Impact: Can drive reimbursement processes.

Do-Not-Use Abbreviations

Hand-off Reports

• Definition: The real-time process of passing patient-specific information from one caregiver to another or among interdisciplinary team members to ensure continuity of care and patient safety.

• Functions of Handoffs:

  • Provide accurate and timely information.

  • Use standardized approach.

  • Encourage patient participation.

  • Note: Transitioning involves risks.

SBAR Communication Model

• Situation: What is happening at the current time?

• Background: What are the circumstances leading up to this situation?

• Assessment: What does the nurse think the problem is?

• Recommendation: What should we do to correct the problem?

Verbal and Telephone Orders

• Usage: Limit to emergency situations only.

• Confirmations: Repeat order verbatim to confirm accuracy.

• Documentation Requirements:

  • Document as a verbal/phone order.

  • Include the date/time, HCP name, and nurse’s signature.

  • Co-sign often required within a defined time frame.

Incident Reports

• Purpose: Completed when unusual/unexpected event occurs involving patient, visitor, or staff member.

• Functions:

  • Document details of the incident.

  • Keep workplace safe.

  • Identify trends.

  • Analyze root cause of incident.

  • Make necessary adjustments to prevent recurrence.

• Characteristics: Must be objective, nonjudgmental, and factual.

• Note: Incident reports are NOT a part of the medical record.

Health Literacy

• Definition: The ability to obtain, process and understand basic information and services needed to make appropriate health decisions and follow instructions for treatment.

Health Literacy: Expected Patient Competencies

• Skills Needed:

  • Read and identify credible health information.

  • Understand numbers in the context of the patient’s health care.

  • Make appointments and fill out forms.

  • Gather health records and ask appropriate questions of health care providers.

  • Advocate for appropriate care.

  • Navigate complex insurance programs.

  • Use technology to access information and services.

Factors Affecting Health Literacy

• Demographic Factors:

  • Age

  • Culture

  • Language

  • Environment

• Content Factors:

  • Nature of the content being taught.

• Context Factors:

  • Current situation of the patient.

• Learning Factors:

  • Learning style of the patient.

Indicators of Inadequate Patient Health Literacy

• Signs:

  • Incomplete or inaccurate information on forms.

  • Patient requests written documents be read aloud (e.g., “I left glasses at home”).

  • Missed appointments.

  • Lack of follow-through for labs, imaging tests, or referrals.

  • Noncompliance with medication/treatment regimens.

Nurse’s Role in Patient Teaching

• Responsibilities:

  • Provide patients with easy-to-understand information.

  • Speak in a clear voice, using short sentences.

  • Use multiple teaching methods to meet the needs of all types of learners.

  • Encourage active involvement of patient and families.

  • Reassess/evaluate learning (in a supportive manner) after 2-3 key points introduced.