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Communication & Documentation
This document discusses communication in healthcare. It defines communication and describes its components and process. It discusses different types of communication including verbal, nonverbal, intrapersonal, interpersonal, and group communication. It outlines the sender, message, channel, receiver, and feedback elements of the communication process. It also discusses therapeutic communication techniques used in healthcare to develop trust and show caring. Barriers to communication and factors that affect communication are also summarized.
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Communication & Documentation
- 1. B Y : MU H A M M A D B A Q A R RN, BSN, MSPH COMMUNICATION
- 2. COMMUNICATION Communication isthe process people use to exchange information through verbal and nonverbal messages. Communication is the giving and receiving of information. Sharing or transmitting thoughts or feelings
- 3. COMMUNICATION LEVELS IntrapersonalCommunication Interpersonal Communication Group Communication Public Speaking
- 4.
- 5. COMMUNICATION COMPONENTS Content Thecontent of communication describes the actual subject matter, words, gestures, and substance of the message. It is the message that everyone may hear or see. Process Process refers to the act of sending, receiving, interpreting, and reacting to a message.
- 6.
- 7. BASIC 5 FIVEELEMENTS OF THE COMMUNICATION PROCESS Communication Process Feedback Sender Messages The channel Receiver
- 8. SENDER Begins theconversation to deliver a message (content) to another person. The sender, also called the source or the encoder, uses verbal and nonverbal methods to transmit the message. • Encoding: Refers to the process of selecting the words, gestures, tone of voice, signs, and symbols used to transmit the message.
- 9. MESSAGE Is theverbal and/or nonverbal information the sender communicates. It might be content of a : • Conversation • Speech • Gesture • Letter, and • So forth
- 10. EFFECTIVE MESSAGES Complete Clear Concise Organized timely, and Expressed in a manner that the receiver can understand.
- 11. THE CHANNEL Isthe medium used to send the message. Examples: • Face-to-face communication is a commonly used channel. • Nurses frequently use touch as a nonverbal way to communicate caring and concern
- 12. THE CHANNEL Otherchannels include: • Written pamphlets • Audiovisual aids • Recordings • Telephone • Text messages, and • The Internet
- 13. RECEIVER: Is theperson who receives the decodes the message. The receiver is the observer, listener, and interpreter of the message. Interpretation, also called decoding: The receiver uses to decode the message • Visual • Auditory, and • Tactile senses
- 14. FEEDBACK Is themessage returned by the receiver. It indicates whether the meaning of the sender’s message was understood.
- 15. FORMS OF COMMUNICATION Verbal Communication Nonverbal Communication
- 16. VERBAL COMMUNICATION Isthe use of spoken and written words to send a message. Examples: Speaking, Listening, Writing, Reading. Occurs on a more Conscious level Verbal message goal is that the receiver will understand both sender words and sender meaning
- 17. CHARACTERISTICS OF THEEFFECTIVE VERBAL COMMUNICATION Pace and intonation: The manner of speech, rate or rhythm and tone Simplicity: commonly understood words, shortness, and completeness Clarity and brevity: simple and clear. Timing and relevance: Asking question . Appropriate , ensure words are heard. encourage the client to express concerns, and then to deal with those concerns.
- 18. CHARACTERISTICS OF THEEFFECTIVE VERBAL COMMUNICATION Adaptability: Adjust spoken messages with behavioral cues from the client Modify client tone of speech and express concern by facial expression while moving toward the client. Credibility: worthiness of belief, trustworthiness, reliability and sincerity Humor: The physical act of laughter can be an emotional and physical release.
- 19. NONVERBAL COMMUNICATION (or bodylanguage) Is the exchange of messages without the use of words. Occurs on a more unconscious level. Non-verbal communication is sometimes considered a more accurate description of true feelings because one has less control over non-verbal
- 20. NONVERBAL COMMUNICATION (or bodylanguage) Examples: Gestures Facial Expressions Posture and Gait Tone of Voice Touch Eye Contact Body Position Physical Appearance
- 21. FUNCTIONS OF COMMUNICATION Information Education Motivation point of view Counseling Rising morals Health development Organization Enhance productivity Conflict resolution
- 22. FACTORS AFFECT COMMUNICATION Environment Developmental Variations Gender Values and Perceptions Territoriality Sociocultural Factors Roles and Relationships Judgment Personal Space o Intimate: Touching(0) to 18 inches o Personal: 18 Inches to 4 feet o Social: 4 to 12 feet o Public: 12 to 15 feet
- 24. THERAPEUTIC COMMUNICATION Aninteraction between a health care professional and a patient that aims to enhance the patient's comfort, safety, trust, or health and well-being. Sometimes called effective communication, it is purposeful and goal-oriented, creating a beneficial outcome for the client
- 25. GOALS OF THERAPEUTIC COMMUNICATION To obtain or provide information To develop trust To show caring To explore feelings
- 26. THERAPEUTIC COMMUNICATION TECHNIQUES Therapeuticcommunication techniques are specific responses that encourage the expression of feelings and ideas and convey acceptance and respect.
- 27. THERAPEUTIC COMMUNICATION TECHNIQUES ActiveListening Sharing Observations Sharing Empathy Sharing Hope Sharing Humor Sharing Feelings Using Touch. Using Silence Providing Information Clarifying. Focusing. Paraphrasing. Asking Relevant Questions Summarizing Concreteness and Confrontation.
- 28. NON THERAPEUTIC COMMUNICATION TECHNIQUES Asking Personal Questions Giving Personal Opinions. Changing the Subject False Reassurance Sympathy Asking for Explanations Ask Approval or Disapproval Defensive Responses Passive or Aggressive Responses Arguing
- 29. COMMUNICATION SKILLS Knowyourself Be honest with your feelings Be sure in your ability to relate to people Be sensitive to needs of others Be reliable Recognize symptoms of anxiety Watch your non-verbal reactions Use words carefully Recognize differences Recognize and evaluate your own actions and responses.
- 30. COMMUNICATING WITH CARE Keep your attention in the moment and on the patient. While the patient is sharing personal information, tune in and do not multitask. Maintain eye contact while listening. Do not interrupt the patient. Avoid looking at your cell phone or watch. Never text while the patient is talking. Do not casually talk with coworkers while the patient is waiting.
- 31. PSYCHOSOCIAL ASPECTS OF COMMUNICATION Style. Gestures. Meaning of time. Meaning of space. Cultural values. Political correctness
- 32. NURSE CLIENT COMMUNICATION Almost every nurse-client interaction should involve therapeutic communication. Nurse-client communication is influenced by both the nurse and the client.
- 33. THE THERAPEUTIC RELATIONSHIP The therapeutic relationship consists of four phases: Pre-interaction Phase Orientation Phase Working Phase Termination Phase
- 34. PRE-INTERACTION PHASE Before meetinga patient: Review available data, including the medical and nursing history. Talk to other caregivers who have information about the patient. Anticipate health concerns or issues that arise. Identify a location and setting that fosters comfortable, private interaction. Plan enough time for the initial interaction.
- 35. ORIENTATION PHASE/ INTRODUCTION When thenurse and patient meet and get to know one another: Set the tone for the relationship by adopting a warm, empathetic, caring manner. Recognize that the initial relationship is often superficial, uncertain, and tentative. Expect the patient to test your competence and commitment. Closely observe the patient and expect to be closely observed by the patient.
- 36. ORIENTATION PHASE/ INTRODUCTION Assess the patient’s health status. Clarify the patient’s and your roles. Form contracts with the patient that specify who will do what. Let the patient know when to expect the relationship to be terminated.
- 37. WORKING PHASE Theactive part of the relationship The nurse communicates caring The patient expresses thoughts and feelings Mutual respect is maintained Honest verbal and nonverbal expression occurs Key communication goals are o To assist the client to clarify feelings and concerns
- 38. TERMINATION PHASE During theending of the relationship Remind the patient that termination is near. Evaluate goal achievement with the patient. Talk about the relationship with the patient. Separate from the patient by relinquishing responsibility for his or her care. Achieve a smooth change for the patient to other caregivers as needed.
- 39. THERAPEUTIC COMMUNICATION ELEMENTS Trustand honesty: Avoid giving false reassurances Empathy :Show a sense of understanding and acceptance of the patient’s situation. Respect and courtesy: Use titles and names that are acceptable to the patient. Encourage active participation in the decision- making process. Privacy and confidentiality : Use during both the interaction and away from the interaction.
- 40. BARRIERS TO THERAPEUTIC INTERACTION Language Differences Cultural Differences Gender Developmental Level Health Status Knowledge Differences Emotional Distance Emotions Daydreaming
- 41. DETERMINANT FACTORS IN COMMUNICATION Anurse’s communication is affected by: Past Experience State of Health Home Situation Workload Staff Relations Self-Awareness
- 42. DETERMINANT FACTORS IN COMMUNICATION Aclient’s communication is affected by: Social Factors Religion Family Situation Level of Consciousness Stage of Illness Visual, Hearing and Speech Ability Language expertise
- 43. COMMUNICATION WITHIN THE HEALTHCARE TEAM Providing care is a team effort. To ensure efficiency and effectiveness, effective communication is necessary. This communication may be oral or written.
- 44. THE NURSE’S WAYSOF COMMUNICATION Oral Written Self-Reflection
- 45.
- 46. DOCUMENTATION Written evidence of: The interactions between and among health care professionals, clients, their families, and health care organizations. The administration of tests, procedures, treatments, and client education. The results of, or client’s response to, diagnostic tests and interventions
- 47. DOCUMENTATION Documentation isthe act of recording patient status and care in written or electronic form, or in a combination of the two forms. Is anything written or printed on which you rely as record or proof of patient actions and activities. Documentation in the health record is an integral(essential)part of safe and effective nursing practice
- 48. DOCUMENTATION PURPOSE Communication Continuity of Care Quality Improvement Planning and Evaluation of Patient Outcomes Legal Documentation Professional Standards of Care Reimbursement and Utilization Review Education and Research
- 49. What Should beDocumented in the Medical Record? Identification Data. Medical History. Physical Examinations. Diagnostic And Therapeutic Order. Appropriate Consent. Reports Of Procedures. Results Of Tests. Conclusions At The Termination Of Care
- 50. CHARACTERISTICS OF DOCUMENTATION Complete Correct Timely Legal Professional Brief OR concise Comprehensive Factual
- 51. METHODS OF DOCUMENTATION Narrative Charting Source-oriented charting Problem-oriented charting PIE charting Focus charting Charting by exception Computerized documentation Case management with critical paths
- 52. NARRATIVE CHARTING Thistraditional method of nursing documentation takes the form of a story written in paragraphs. Before the advent of flow sheets, this was the only method for documenting care. About 30% of nurses’ time, during an 8-hour shift. Time-consuming
- 53. SOURCE-ORIENTED CHARTING Anarrative recording by each member (source) of the health care team on separate records. Unstructured time-consuming
- 54. PROBLEM-ORIENTED CHARTING Wasintroduced in 1969 by Lawrence Weed. Developed on a medical model Structured Focuses on the client’s problem and employs a structured, logical format called SOAP or or SOAPIER charting
- 55. PROBLEM-ORIENTED CHARTING o Subjectivedata (what the client states or family states) o Objective data (what is observed/inspected) o Assessment:Interpretation of meaning of subjective and objective data o Plan (actions to be taken to relieve client’s problem)
- 56. PROBLEM-ORIENTED CHARTING Implementation: Specificinterventions Evaluation: Effectiveness of the plan Revision: Recommended changes
- 57. PIE CHARTING Wasintroduced at Craven Regional Medical Center in 1984 to streamline documentation. PIE charting has a nursing origin. PIE is an acronym for: o Problem o Intervention o Evaluation of Nursing care Includes: o flow sheet o Nursing progress notes
- 58. FOCUS CHARTING Focuscharting was created in 1981 at Eitel Hospital in Minneapolis. A documentation method that uses a column format to chart data, action, and response (DAR). Not limited to client “problems” but allows for the identification of all “concerns” (e.g., results of a diagnostic test)
- 59. CHARTING BY EXCEPTION(CBE) CBE was introduced in 1983 by St. Luke Medical Center in Milwaukee. A documentation method that requires the nurse to document only deviations from pre-established norms. Three key components: o Flow sheets: Highlight significant findings Reference documentation: Is related to the standards of nursing practice. Bedside accessibility : Is related to the documentation forms.
- 60. COMPUTERIZED DOCUMENTATION Decreaseddocumentation time. Increased legibility and accuracy. Clear, decisive, and concise words. Statistical analysis of data. Enhanced implementation of the nursing process. Enhanced decision making. Multidisciplinary networking.
- 61. CASE MANAGEMENT WITHCRITICAL PATHS A comprehensive, standard plan of care for specific case situations. The pathway is monitored to ensure that interventions are performed on time and client outcomes are achieved on time.
- 62. FORMS FOR RECORDINGDATA Worksheets and Kardex Flow Sheets Nurse’s Progress Notes Discharge Summary Other o Report etc
- 63. WORKSHEETS AND KARDEX A summary worksheet reference of basic information that traditionally is not part of the record. Usually contains: o Client data (name, age, marital status, religious preference, physician, family contact). o Medical diagnoses: listed by priority. o Nursing diagnoses: Listed by priority o Allergies. o Medical orders (diet, medications, diagnostic tests, etc.). o Activities permitted.
- 64. FLOW SHEETS Verticalor horizontal columns for recording dates and times and related assessment and intervention information. Also included are notes on: o Client teaching. o Use of special equipment. o IV Therapy.
- 65. NURSE’S PROGRESS NOTES Used to document: o Client’s condition, problems, and complaints. o Interventions. o Client’s response to interventions. o Achievement of outcomes. Progress notes include the following forms: o Nurses’ notes o Medication administration o intake and output o teaching records etc
- 66. DISCHARGE SUMMARY Highlightsclient’s illness and course of care. Includes: o Client’s status at admission and discharge. o Brief summary of client’s care. o Intervention and education outcomes. o Resolved problems and continuing care needs. o Client instructions regarding medications, diet, food- drug interactions, activity, treatments, follow-up and other special needs.
- 67. Reports Are oral,written, or audiotape exchanges of information between caregivers Reporting is the verbal communication of data regarding the client’s health status, needs, treatments, outcomes, and responses (Eggland & Heinemann, 1994).
- 68. Types of Reporting Summary Reports Walking Rounds Telephone Reports and Orders
- 69. LEGAL DOCUMENTATION Themedical record serves as a legal document for recording all client activities assessed and initiated by health care practitioners.
- 70. LEGAL DOCUMENTATION/ GENERAL DOCUMENTATIONGUIDELINES Stored according to all governing laws and also to the policies of the hospital Use blue or black ink unless you are using a computer or your hospital uses a special ink color for different shifts. Do not use pencil or ink that can be erased. Write so that it can be read clearly
- 71. LEGAL DOCUMENTATION/ GENERAL DOCUMENTATIONGUIDELINES Date all of your notes. Write the time that you took your notes. Sign your full name and title (RN, LPN etc). Do not draw out things if you make a mistake. Write only the facts be professional and never add personal comments or feelings. Do not use abbreviation unless they are accepted for use by your hospital. Keep all medical records in a safe and secure place;
- 72. LEGAL DOCUMENTATION/ GENERAL DOCUMENTATIONGUIDELINES Do not allow anyone to touch or look at your medical records unless they are a healthcare worker assigned to take care of the patient; Do not discuss any facts of the patient or their care with anyone other than the assigned healthcare staff or the patient themselves. Identify the client and write legally ,Spell correctly. Record each phone call to a physician, including the exact time, message, and response
- 73. CONCLUSION The basiccomponents of the communication process are the sender , message, channel, receiver, and feedback Communication is a dynamic process that is influenced by culture, gender, past experiences, emotions . Therapeutic communication is used to ensure that effective interpersonal communication occurs with the patient . Documentation is a written form of communication that is valuable for continuity of care, quality assurance, legal evidence, reimbursement justification, research, and education.