Transcript Communications

CHARTING
DOCUMENTATION
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DATE
TIME
PLACE
SIMPLE EXPLANATION
TO WHOM
WHO WAS PRESENT
WHAT WAS DONE
SIGNATURE
INFORMED CONSENT
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Simple Consent
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Express consent
Implied consent
Inadequate Consent
MALPRACTICE
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Depends on job description
MEDICAL RECORDS
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Chart contains everything
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Entries must have date, time and signed with
credentials
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Abbreviations must be approved by institution.
GOOD SAMARITAN LAWS
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TO PROTECT PERSONS WHO GIVE
MEDICAL AID IN EMERGENCY
SITUATIONS.
Cardiac Arrest Survival Act provides immunity
for those who purchase Automatic External
Defibrillators (AED).
COMMUNICATION
Effective communication skills allow you to
establish and maintain good working relationships
with patients, patients’ families and other health
care professionals.
FACTORS AFFECTING
COMMUNICATION
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Perceptions
Values
Personal Space
Emotions
Sociocultural Background
Knowledge
Environment
COMMUNICATION PROCESS
SENDER
RECEIVER
COMMUNICATION PROCESS
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VERBAL
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NON-VERBAL: Stress; Contradict; Accent;
Regulate; Substitute
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LEVELS OF COMMUNICATION
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Intrapersonal
Interpersonal
PERSONAL SPACE
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SOCIAL DISTANCE
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PERSONAL DISTANCE
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INTIMATE DISTANCE
LISTENING SKILLS
MOST COMMUNICATION TIME IS
SPENT LISTENING!
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Good eye contact
Watch for non-verbal signs
Don’t cut patient off
Be comfortable with silence
COMMUNICATION
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#1 CAUSE FOR LAW SUITS!!
CULTURAL DIFFERENCES
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Show respect
Treat all equally
Be aware of your own and patient’s nonverbal
messages
If you do not understand something, ask for
clarification
Humor
Gender
TIP
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In some cultures it is disrespectful to speak of
the dead. Patient may be reluctant to provide
detailed information on the family health
history of dead relatives. Ask the patient if
there has been any history of specific diseases
in the family and not focus on the specific
individual if that person is deceased. If
unsuccessful, explain importance of this info,
as it may provide clues to the patient’s
condition.
TIP
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Some Asian cultures calculate age from
conception, not from the actual birth date. A
newborn infant would be considered one year
old. It is important to differentiate for
pediatric patients because of the link between
age and developmental milestones.
SPECIAL COMMUNICATION
SITUATIONS
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Sensory Alterations
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Sensory Deficit
Sensory Deprivation
Sensory Overload
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Altered Consciousness
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Chemical Influence
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Drug use
Drug misuse
Drug abuse
Patient Assessment
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Data Collection
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Data Analysis
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Planning and Implementation
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Evaluation
Data Collection
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Subjective: Anything the patient or
person accompanying pt says that can
affect the procedure
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Objective: What you see, hear, smell feel,
or read in the patient’s chart
Data Analysis
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Integrate Critical thinking by listing all
subjective and objective date, then
analyze.
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What data is relevant to the procedure?
Planning and Implementation
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After analyzing the data you come up
with a plan to take the x-ray and
implement.
Evaluation
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Were the patient’s needs met?
Was the patient’s safety maintained?
Was the patient’s skin intact?
Did the pt complain of pain during exam?
What problems occurred that I didn’t plan for?
Any discomfort to patient?
Did I use higher-level critical thinking to
complete procedure?
Activity
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John Gomez reports to the outpatient desk for
a scheduled upright abdomen and UGI series.
He states he feels ill and has had nausea and
vomiting for 24 hours. His family is also ill.
He is pale, sweating and dizzy when standing.
He doesn’t think he will be able to swallow the
barium What is the chief complaint? List
objective and subjective data. What is your
plan?
Developing Harmonious
Relationship
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Establishing guidelines
Reducing Distance
Listening
Using silence
Responding to
underlying message
Restating main idea
Reflecting main idea
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Seeking and providing
Clarification
Making observations
Exploring
Validating
Focusing
REFER TO TEXT
AMERICANS WITH DIABILITIES
ACT
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1990 Congress passed this to provide civil
rights protection to persons with disabilities.
Defines a disabled individual as “one who has
a physical or mental impairment that
substantially limits one or more major life
activities”
Provides equal employment opportunity
GREIVING PROCESS
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Denial
Anger
Bargaining
Depression
Acceptance
CASE STUDY
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Mr. Gomez is an elderly Mexican-American patient
who has come to the radiology department for an
abdominal radiograph. He has been diagnosed with
colon cancer and has undergone a surgical procedure
that resulted in a colostomy. He speaks very little
English. His wife and daughter are with him. His
wife is visibly upset and uncomfortable being in the
hospital. How would you explain the procedure to
Mr. Gomez? Would you involve his family?
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Mr Gomez us very uncomfortable lying flat on his
back and says that he just wants to be left alone to
die. How would you handle this situation?
DEATH AND DYING
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Communication issues
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Be open to talk about anything dying pts want
Discuss feelings about loss
Listen!!
Dying Patient’s Rights