Communication and Documentation

Legal Prudence

-Accurate, complete documentation should give legal protection to the nurse, the patient's other caregivers, the healthcare facility, and the patient. -Admissible in court as a legal document, the clinical record provides proof of the quality of care given to a patient. -Documentation is usually viewed by juries and attorneys as the best evidence of what really happened to the patient. -For the best legal protection, the nurse should not only adhere to professional standards of nursing care but also follow agency policy and procedures for intervention and documentation in all situations, especially high-risk situations

communicating with older adults

-Assess for hearing and visual deficits -Give time for elders to formulate responses -Wait for an answer to one question before asking another -Obtain feedback

General Guidelines for Recording

-Date and Time -Timing -Legibility -Permanence -Accepted Terminology -Correct Spelling -Signature -Accuracy -Sequence -Appropriateness -Completeness -Conciseness -Legal Prudence -because a patient's medical record is a legal document and may be used to provide evidence in court, many factors are considered in recording. -Healthcare personnel must not only maintain the confidentiality of the patient's record but also meet legal standards in the process of recording.

Accepted Terminology

-Joint Commission- keeps running list of accepted abbreviations -Use only commonly accepted abbreviations, symbols, and terms as specified by the agency. -Many abbreviations are standard and used universally; others are used only in certain geographic areas. -Many healthcare facilities supply an approved list of abbreviations and symbols to prevent confusion. -A large number of healthcare facilities are now moving away from the use of any abbreviations. -When in doubt about whether to use an abbreviation, write the term in full until certain about the abbreviation

The Nurse's Evidence of the Nursing Process

-Regardless of the record system used in an agency, nurses document evidence of the nursing process on a variety of forms throughout the clinical record -Admission Nursing Assessment- comprehensive admission assessment- can be organized for a specific floor -Nursing Care Plans- Joint Commission REQUIRES that the clinical record include evidence of patient assessments, nsg dx, pt needs, nsg intervention, pt outcomes, and evidence of current nurse plan. -Flow Sheets-Graphic record (VS), I&O, MAR, Skin assessment -Progress Notes- made by nurses about pt progress toward outcomes. -Nursing Discharge/Referral Summaries-Usually an agency provide form. -Facility-specific Documentation •Long-term- with 2 types of care skilled intermediate, •Home Care- part at agency and part at home.

termination

-Summarize important points ●Discuss plan of care

telephone communication

-The nurse receiving a telephone report should document the date and time, note the name of the individual giving the information and subject of the information received, and then sign the notation. -The individual receiving the information should repeat it back to the sender to ensure accuracy. -he nurse must be concise and accurate. -usually include the patient's name and medical diagnosis, changes in nursing assessment, vital signs related to baseline vital signs, significant laboratory data, and related nursing interventions.

Handoff communication

-a verbal or written exchange of information that encompasses the nursing care that has been provided along with all members of the healthcare team who have cared for the patient during the relevant time period -involves two groups, the senders and the receivers. -The senders are the caregivers who are transmitting patient information and releasing care; -the receivers are the caregivers who are accepting the patient and the patient's information.

care plan conference

-allow for collaborative reporting among the healthcare professionals who provide care to the patient. -most often used for patients who have complex care needs. -the patient's healthcare providers discuss possible solutions to certain problems of the patient, such as an inability to cope with an event or lack of progress toward goal attainment. -the choice of healthcare professionals who are invited to attend the conference is based on the needs of the patient. -are most effective when there is a climate of respect—that is, nonjudgmental acceptance of others even though their values, opinions, and beliefs may seem different.

Correct Spelling/legibility

-black pen, any mistake draw line through and initial next to it -it is essential for accuracy in recording. -If unsure how to spell a word, the nurse should look it up. -Two decidedly different medications may have similar spellings with serious patient safety considerations, such as Fosamax and Flomax.

documentation do's

-chart a change in a patient's condition and show that follow-up actions were taken. -Read the nurses' notes prior to care to determine whether there has been a change in the patient's condition. -Be timely. A late entry is better than no entry; however, the longer the period of time between actual care and charting, the greater the risk for recording inaccurate information or omitting necessary information. -Use objective, specific, and factual descriptions. -Correct charting errors in the manner specified by agency policy. -Chart all teaching. -Record the patient's actual words by putting quote marks around the words. -Chart the patient's response to interventions. -Review your notes. Are they clear? Do they reflect what you want to say?

change of shift report

-is a type of handoff communication given to all nurses on the next shift. Its purpose is to provide continuity of care for patients by providing the new caregivers with a quick summary of patient needs and details of care to be given. -may be written or given orally, either in a face-to-face exchange or by audio recording. -the face-to-face report permits the listener to ask questions during the report; -written and audio-recorded reports are often briefer and less time consuming. -sometimes given at the bedside, and patients as well as nurses may participate in the exchange of information.

telephone order

-many agencies allow only registered nurses to take telephone orders. -The increased use of electronic records and communications is reducing the use of telephone orders, as electronic transmission of orders allows for greater accuracy. -the nurse should write the complete order down and read it back to the primary care provider to ensure accuracy. -Question the primary care provider about any order that is ambiguous, unusual (e.g., an abnormally high dosage of a medication), or contraindicated by the patient's condition. -Then transcribe the order onto the physician's order sheet, indicating it as a verbal order (VO) or telephone order (TO). -Once transcribed onto the physician's order sheet, the order must be countersigned by the primary care provider within a time period described by agency policy (24 hours)

appropriateness

-record only info pertaining to pt's health problems or care. -Any other personal information that the patient conveys is inappropriate for the record. -Recording irrelevant information may be considered an invasion of the patient's privacy and/or libelous. -For example, a patient's disclosure that she is recently divorced would not be recorded on her medical record unless it had a direct bearing on her health problem.

consiseness

-recordings need to be brief as well as complete. -Recordings need to be brief as well as complete to save time in communication. -The patient's name and the word patient are omitted. -For example, write, "Perspiring profusely. Respirations shallow, 28/min." -End each thought or sentence with a period.

signature

-write first initial, last name, student nurse at Gadsden State -Each recording on the nursing notes is signed by the nurse documenting it. -The signature includes the name and title, for example, "Susan J. Green, RN" or "S. J. Green, RN." -With computerized charting, each nurse has her own code, which allows the person who entered the documentation to be identified.

intimate zone

0-18 inches interaction between parents and children or people who desire close personal contact

public zone

12-25 feet communication when speaking to an audience or small groups

personal zone

18 inches-4 feet distance when interacting with close friends

social zone

4-12 feet space when interacting with acquaintances such as in a work or social setting

Accuracy

Be precise • Quantify whenever possible • Be sure to make clear who gave the care• -When countersigning with a student or another nurse, review the content of the documentation and document your own follow-up assessment, interventions if any, and the patient's response -ensure you are in the correct chart or electronic record. -write facts or objective observations rather than opinions or interpretations -avoid general words, such as large, good, or normal, chart specific data

documentation donts

Chart in advance of the event (e.g., procedure, medication). Use vague terms (e.g., "appears to be comfortable," "had a good night"). Chart for someone else. Use "patient" instead of the patient's name. Alter a record even if requested by a superior or a physician. Record assumptions or words reflecting bias (e.g., "complainer," "disagreeable").

purpose of patient records

Communication - the method in which different healthcare workers who interact with the patient communicate with each other. ALLOWING for consistency in patient care. Planning patient care - Each health care providers uses the patient's DATA recorded in the patient's chart to plan care. Nurse records temperature, MD reads and makes changes in medication. Auditing health agencies- the joint commission will review patient records to ensure a health agency is meeting required standards of care. Research Valuable source of data Education - comprehensive view of patient's treatment, illness, strategies Reimbursement- Documents must contain the correct codes for diagnosis and treatment for agencies to receive payment, Medicaid , insurance, third parties. Also shows if additional treatment may be needed for the recommendations of the illness. Legal documents- Patient's record is a legal document, Admissible in court as evidence. Healthcare analysis- helps identify agency needs overuse versus underused for hospital services.

sequence

Document events in the order in which they occur; for example, record assessments, then the nursing interventions, and then the patient's responses. Update as needed or according to agency protocols.

therapeutic relationship

Helping is growth-facilitating process that strives to achieve two basic goals 1. Help pt manage their problems of living more effectively and develop unused or underused opportunities more fully 2. Help pt become better at helping themselves in their everyday lives. Develops in minutes or weeks. Key is trust and acceptance. With the pt believing the nurse cares and wants to help the pt. Lots affect the relation ship besides good communication skills. Age, gender, culture, setting, etc. So lets define the relationship: Emotional as well as intellectual bond NR/PT Respects the pt as an individual:::: Max the pt ability to participate in decision making and tx Considering ethnic background and cultural practices. Respects pt confidentiality Focuses on the pt well being based on mutual trust, respect and acceptance

assertive communication

Means of communication that is not pushy or bossy but is also not soft. Useful in dealing with upset customers as it both defuses their anger and gives them confidence that you know what you're doing. •Benefits •Techniques •"I" statements •Fogging •Negative assertion •Repetition •Confidence •Managing nonverbal •Thinking before speaking •Avoiding apologizing

modes of communication

Process by which information is exchanged between individuals through a common system of symbols, signs, or behavior. •Verbal Communication •Nonverbal Communication •Electronic Communication •Written Communication

SBAR

S: Situation B: Background A: Assessment R: Recommendation -Hand-off communication can occur with other hospital departments, nurse-to-nurse report, or nurse-to-physician discussions. -In an effort to eliminate breakdowns in communication and potential adverse events, the Joint Commission (TJC) includes a goal to improve the effectiveness of communication among caregivers as a National Patient Safety Goal. -Both TJC and the Institute for Healthcare Improvement (IHI) have recommended using these clear and consise way of reporting to improve hand-off communication. -originally developed by the U.S. Navy to accurately transmit critical information and initially adapted by Kaiser Permanente of Colorado to facilitate nurse and physician communication.

SBAR hand off example

Situation-Provide description of the patient's dyspnea and chest pain. Background-Provide an explanation that the patient had a PEG placement this morning and that relatively recently she began complaining of chest pain. Assessment-Provide an assessment that the patient is most likely having a cardiac event or pulmonary embolism. Recommendation-Provide a recommendation that the physician see the patient immediately and that the patient be started on an O2 stat.

Documentation timing

When a medical record is examined in a malpractice or negligence case, date and time are critical in establishing a timely response to a patient need. • Resist the temptation to leave documentation until the end of the shift • You may forget key pieces of information when rushing • Charting as your shift progresses will help keep your documentation accurate • Professionals in other disciplines and nurses who provide temporary coverage need to have up-to-date information available in the record • Other professionals who access the record need to have up-to-date data to guide care • Computer entries are automatically date-and-time stamped. When your entry refers to earlier events, note the time to which you are referring • NEVER document in advance- This practice is illegal falsification of the record

therapeutic communication

is client centered and goal oriented; may share a personal experience to show understanding for client's situation -1st step to establishing a trusting relationship •Interactive process between the nurse and the patient. •Face-to-face interaction that focuses on advancing the physical and emotional well-being of a patient. Nurses use therapeutic communication techniques to provide support and information to patients. You may need to use a variety of techniques to accomplish your nursing goals in communicating with a patient. -Always introduce yourself and explain all procedures to your patient and/or care giver Control the tone of your voice Be knowledgeable about the topic of conversation Be flexible Be clear and concise Avoid words that might have different interpretations Be truthful Keep an open mind Take advantage of available opportunities Sit when communicating with a patient Be alert and relaxed and take your time Keep the conversation as natural as possible Maintain eye contact if appropriate Use appropriate facial expressions and body gestures Think before responding to the patient Do not pretend to listen Listen for themes in the patient's comments Use silence, therapeutic touch, and humor appropriately

verbal communication

is using words- spoken or written. Must consider what the patient's primary language is....English may be second. What are you going to do?? Includes: Spoken and written word Tone Volume Cadence Cultural differences Jargon Slang

nonverbal communication

is without using words. Uses all 5 senses. Make sure what the patient is telling you is the way that they are acting. "I am ok" while doubled over in pain with facial grimacing. * Touch- can mean different things to different people...must be careful, but it is very helpful with patient's * Eye contact- Suggest respect and willingness to listen and it keeps communication open. Must be careful with different cultures, some feel as maintaining eye contact is invasive, rude. * Facial expressions- must learn to control yours as a nurse, some people are an open book with facial expressions, you have to hide them at times, learn this skill. * General appearance- dehydration will leave skin dry, sick may be green in color, dressing, grooming * Sounds- groans, moans, gasp, sigh •Silence is a great thing. The patient may be trying to find the right words to describe. Very important to learn the skill of silence. •Electronic and Written email, text, social media, - •Not all have access to technology. Providers using their phone to communicate could do so at an inappropriate time. Confidenality, how things are written, correct grammar spelling.

developing rapport with children

it's a nurse family child relationship and can use the same techniques as an adult have to react to the individual. Estab Rapport: •same eye level •Show interest in what child does •Compliment the child •Use calm tone in voice and developmentally appropriate •Pace the discussion so child does not feel rushed •Explain the concept the child can understand •Include the child in the discussion of care if developmentally appropriate •Listen more than you talk, avoid distractions. Etsab Trust: Trust is critical Strategies for trust-Follow through on promises made to the child/respect confidentiality/be truthful even when not what is wanted to be heard.

working phase

obtain patient information ●Invite the patient's story "Tell me about... Do not interrupt or inject your own experiences or opinions. ●Identify and respond to emotional clues: Naming—Understanding—Respecting Naming—"That sounds like a scary experience"; Understanding or legitimization—"It's understandable that you feel that way"; and Respecting—"You've done better than most people would with this." ●Expand and clarify the patient's story OLD CART ●Generate and test diagnostic hypotheses ●Negotiate a plan, including further evaluation, treatment, education and self-management support and prevention

orientation phase

put the patient at ease and establish trust ●Greet the patient (call them by their name!!! Introduce yourself and your title) and establish rapport and reassure confidentiality, and set guidelines for the "relationship" ●Establish the agenda for the interview: Opened-ended questions vs. Closed-ended questions

pre-interview

set the stage for a smooth interview ●Self-Re-flection: don't bring personal bias to the interview. Patient's values will be different from our own and we must respect that. ●Review patient record: get as much info as possible, but clarify with the patient to ensure that it is correct. ●Set interview goals: Goals range from completing forms for health care institutions, to following up on health care issues, to obtaining a basis for developing a plan of care. Review own clinical behavior and appearance: Posture, gestures, eye contact, and tone of voice; Seem calm and unhurried, even if time is limited. •Make the patient comfortable by adjusting the environment. •Take notes.

completeness

•Condition change •Patient responses, especially unusual, undesired or ineffective response •Use of chain-of-command •Communication with patient and family • Entries in all spaces on all relevant assessment forms •Use N/A or other designation for items that do not apply to your patient •DO NOT LEAVE BLANKS-these are hazardous because they permit entries above your signature, Others may make entries in such blanks by mistake or to purposely falsify records, draw a line if have space before signature on paper charts -Nurses' notes need to reflect the nursing process. -record all assessments, dependent and independent nursing interventions, patient problems, patient comments and responses to interventions and tests, progress toward goals, and communication with other members of the health team. -Care that is omitted because of the patient's condition or refusal of treatment must also be recorded. -Document what was omitted, why it was omitted, and who was notified.

therapeutic techniques

•Empathizing •Active listening •Physical Attending •Using Silence •Reflecting •Imparting Information •Avoiding self disclosure •Clarifying •Paraphrasing •Checking Perceptions •Questioning •Structuring •Pinpointing •Linking •Giving Feedback •Confronting •Summarizing •Processing

Non-therapeutic barriers

•Failure to perceive the patient as a human being •Failure to listen •Using Clichés •Yes or No questions •Why and How questions •Probing Bullying •Using leading questions •Using comment to give advice •Judgmental comments •Changing the subject •Giving false assurance •Gossip and Rumor Incivility

How to develop a therapeutic relationship

•Listen actively •Help ID what the person is feeling •Put yourself in the patient's shoes •Be honest •Be genuine and credible •Use your ingenuity •Be aware of cultural differences •Maintain the patient confidentiality •Know your role and limitations

maintaining confidentiality of patient records

•Patient's record is legally protected as a private record of patient's care •Access is restricted to healthcare professionals providing care to that patient •Rightful owner of the record, the patient and the agency providing the care •Health Insurance Portability and Accountability Act (HIPPA) changes to cover Protected Health Information (PHI)

Who do we communicate with?

•Patients •Families •Health Care Providers •Co-workers •Classmates •Instructors