Questions and Answers
What does the term 'clinical judgment' represent?
Observed outcome of critical thinking + decision making
Circular transactional model of communication includes factors like sender, message, and feedback.
True
Which form of communication involves a healing relationship between a nurse and a patient?
Match the following components of the Circular Transactional Model of communication with their definitions:
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______ is a technique that encourages patients to share their thoughts, goals, beliefs, fears, and concerns.
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What is the main purpose of documentation in healthcare?
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Electronic Health Record (EHR) is an individual's __________ computerized record.
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What does the acronym PHR stand for in healthcare documentation?
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Confidentiality is an essential aspect of maintaining the privacy of health records.
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What is the main role of the American Recovery and Reinvestment Act (ARRA) in healthcare?
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Match the following healthcare documentation forms with their descriptions:
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What is the primary function of Clinical Decision Support Systems (CDSS) in healthcare?
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Morals refer to the study of the ideals of right and wrong behavior.
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What is the main principle behind Deontology in ethics?
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What is the primary purpose of documentation in healthcare?
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Electronic health records (EHR) contain the lifetime computerized record of an individual.
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What is the purpose of the American Recovery and Reinvestment Act (ARRA) related to healthcare?
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______ is the will to do good but the equal commitment to do no harm or hurt.
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Match the approaches to ethics with their descriptions:
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What is the definition of clinical judgment?
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What does competent communication in nursing do?
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Critical thinking applied during patient interactions helps overcome perceptual biases.
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Match the following elements of the circular transactional model with their descriptions:
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What is a broad term that refers to all factors influencing communication? Metac_____________ation.
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What is the typical structure used within healthcare organizations for decision making?
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What is the primary goal of case management in healthcare?
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What is a characteristic of a Magnet hospital?
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What is the role of the RN in healthcare?
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What is the goal of the Institute for Patient-and Family-Centered Care?
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What is the benefit of a decentralized management approach in healthcare?
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What is the focus of the nursing team in achieving the best outcomes for patients?
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What is the stage of the grieving process where the patient is ready to be responsible for learning?
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What is a key aspect of autonomy in patient care?
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What is the primary goal of interprofessional collaboration?
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What is the outcome of critical thinking and decision-making in clinical judgment?
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Who is responsible for making clinical decisions?
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What is the purpose of interprofessional rounding?
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What is accountability in patient care?
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What leads to prioritizing care in patient care?
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What is reflection in clinical judgment?
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What is the primary focus of therapeutic communication?
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What is the benefit of critical thinking in communication?
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What is the role of the sender in the circular transactional model of communication?
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What is the primary goal of competent communication in nursing?
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What is the definition of metacognition?
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What is the role of feedback in the circular transactional model of communication?
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What is the primary characteristic of intrapersonal communication?
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What is the purpose of involving oneself in the situation being communicated?
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What is the primary factor that influences communication within both the sender and receiver?
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What is essential for effective communication in a physical environment?
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What type of communication involves the tone of voice dramatically affecting the meaning of a message?
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What is a technique that encourages patients to share their thoughts, goals, beliefs, fears, and concerns?
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What type of relationships require forming caring relationships with entire families?
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What is a technique used for communicating critical information among healthcare teams?
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What is a form of behavior that sometimes occurs between colleagues in healthcare settings?
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What is the meaning of connotative?
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What is the primary purpose of therapeutic communication techniques?
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What is the opposite of therapeutic communication techniques?
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What is an important consideration when adapting communication techniques to patient needs?
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What is one way to evaluate the success of a patient's plan of care in facilitating communication?
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What happens if expected outcomes for a patient's plan of care are not met?
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Why is it important to consider sociocultural factors in patient communication?
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What is the primary goal of adapting communication techniques to patient needs?
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What is an important aspect of patient-centered communication?
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Study Notes
Informatics and Documentation
- Documentation is a key communication strategy that produces a written account of patient data, clinical interventions, and patient responses.
- The health care record serves multiple purposes:
- Facilitates interprofessional communication
- Provides a legal record of care
- Provides justification for financial billing and reimbursement
- Supports quality and performance improvement
- Serves as a resource for education and research
- Electronic Health Record (EHR) vs. Electronic Medical Record (EMR):
- EHR: individual's lifetime computerized record
- EMR: record for an individual health care visit
- The American Recovery and Reinvestment Act (ARRA) and Health Information Technology for Economic and Clinical Health Act (HITECH) promote the use of EHRs.
Documentation Guidelines
- Maintain privacy, confidentiality, and security of the health care record
- Use passwords and firewalls to protect PHI
- Log out or turn off screens when not in use
- Guidelines for quality documentation:
- Flow sheets, progress notes, and charting by exception (CBE)
- Narrative progress notes in formats like focus charting, SOAP notes, and PIE notes
- Common record-keeping forms within the EHR:
- Admission nursing history form
- Patient care summary
- Care plans
- Discharge summary forms
Ethical Considerations
- Basic terms in health ethics:
- Morals: judgment about behavior based on specific beliefs
- Value: deeply held personal belief about the worth of an idea
- Bioethics: study of ethical, social, and legal issues in biomedicine
- Code of Ethics for Nursing:
- Advocacy: applying skills and knowledge for the benefit of another person
- Responsibility: respecting professional obligations and maintaining competence
- Accountability: answering for one's actions
- Confidentiality: respecting patient privacy
Patient Education
- Goal of patient education: help individuals, families, or communities achieve optimal levels of health
- Effective communication involves feedback from the sender and receiver
- Domains of learning:
- Cognitive: understanding and knowledge
- Affective: attitudes and feelings
- Psychomotor: motor skills
- Teaching plan should consider cultural factors and include feedback mechanisms
Managing Patient Care
- Nursing team: works together to achieve best outcomes for patients
- Effective team development requires:
- Team building and training
- Trust and communication
- Collaborative work environment
- Magnet hospitals:
- Transformed culture with a practice environment that is collaborative
- Clinical promotion systems and evidence-based practice programs
- Professional autonomy and control over practice environment
- Case management: coordinates and links health care services across all levels of care for patients and their families
- Decision making:
- Shared governance: decentralized structure with decision-making at the staff level
- Responsibility: duties and activities employed to perform
- Autonomy: independent decisions about patient care
- Authority: legal ability to perform tasks and assign duties
- Accountability: assuming responsibility for actions and outcomes
Critical Thinking and Clinical Judgment
- Clinical judgment: observed outcome of critical thinking and decision making
- Clinical decision making: technicians or other assistive personnel cannot make immediate decisions
- Reflection: purposefully visualizing a situation and reviewing everything remembered about it
- Importance of critical thinking and clinical judgment in effective communication
Communication
- Competent communication: maintains effective relationships within professional practice and meets legal, ethical, and clinical standards
- Therapeutic communication: occurs within a healing relationship between a nurse and patient
- Critical thinking applied during patient interactions helps overcome perceptual biases or stereotypes
- Circular transactional model of communication:
- Referent: factor motivating communication
- Sender: initiates communication
- Receiver: person to whom message is sent
- Message: information sent or expressed
- Channels: method used to transmit message
- Feedback: message received by sender
- Interpersonal variables: factors within sender and receiver influencing communication
Informatics and Documentation
- Documentation is a key communication strategy that produces a written account of patient data, clinical interventions, and patient responses.
- The health care record serves multiple purposes:
- Facilitates interprofessional communication
- Provides a legal record of care
- Provides justification for financial billing and reimbursement
- Supports quality and performance improvement
- Serves as a resource for education and research
- Electronic Health Record (EHR) vs. Electronic Medical Record (EMR):
- EHR: individual's lifetime computerized record
- EMR: record for an individual health care visit
- The American Recovery and Reinvestment Act (ARRA) and Health Information Technology for Economic and Clinical Health Act (HITECH) promote the use of EHRs.
Documentation Guidelines
- Maintain privacy, confidentiality, and security of the health care record
- Use passwords and firewalls to protect PHI
- Log out or turn off screens when not in use
- Guidelines for quality documentation:
- Flow sheets, progress notes, and charting by exception (CBE)
- Narrative progress notes in formats like focus charting, SOAP notes, and PIE notes
- Common record-keeping forms within the EHR:
- Admission nursing history form
- Patient care summary
- Care plans
- Discharge summary forms
Ethical Considerations
- Basic terms in health ethics:
- Morals: judgment about behavior based on specific beliefs
- Value: deeply held personal belief about the worth of an idea
- Bioethics: study of ethical, social, and legal issues in biomedicine
- Code of Ethics for Nursing:
- Advocacy: applying skills and knowledge for the benefit of another person
- Responsibility: respecting professional obligations and maintaining competence
- Accountability: answering for one's actions
- Confidentiality: respecting patient privacy
Patient Education
- Goal of patient education: help individuals, families, or communities achieve optimal levels of health
- Effective communication involves feedback from the sender and receiver
- Domains of learning:
- Cognitive: understanding and knowledge
- Affective: attitudes and feelings
- Psychomotor: motor skills
- Teaching plan should consider cultural factors and include feedback mechanisms
Managing Patient Care
- Nursing team: works together to achieve best outcomes for patients
- Effective team development requires:
- Team building and training
- Trust and communication
- Collaborative work environment
- Magnet hospitals:
- Transformed culture with a practice environment that is collaborative
- Clinical promotion systems and evidence-based practice programs
- Professional autonomy and control over practice environment
- Case management: coordinates and links health care services across all levels of care for patients and their families
- Decision making:
- Shared governance: decentralized structure with decision-making at the staff level
- Responsibility: duties and activities employed to perform
- Autonomy: independent decisions about patient care
- Authority: legal ability to perform tasks and assign duties
- Accountability: assuming responsibility for actions and outcomes
Critical Thinking and Clinical Judgment
- Clinical judgment: observed outcome of critical thinking and decision making
- Clinical decision making: technicians or other assistive personnel cannot make immediate decisions
- Reflection: purposefully visualizing a situation and reviewing everything remembered about it
- Importance of critical thinking and clinical judgment in effective communication
Communication
- Competent communication: maintains effective relationships within professional practice and meets legal, ethical, and clinical standards
- Therapeutic communication: occurs within a healing relationship between a nurse and patient
- Critical thinking applied during patient interactions helps overcome perceptual biases or stereotypes
- Circular transactional model of communication:
- Referent: factor motivating communication
- Sender: initiates communication
- Receiver: person to whom message is sent
- Message: information sent or expressed
- Channels: method used to transmit message
- Feedback: message received by sender
- Interpersonal variables: factors within sender and receiver influencing communication
Patient Care Management
- Resolution in the patient care process involves expressing emotions openly, realizing the impact of illness, asking questions, and taking responsibility for learning.
- Acceptance involves actively pursuing information and striving for independence.
Nursing Team
- A strong nursing team works together to achieve the best outcomes for patients, requiring team building, training, trust, communication, and a collaborative workplace.
- Magnet hospitals have a transformed culture, clinical promotion systems, research-based practice, and evidence-based practice programs, providing nurses with professional autonomy and control over their practice environment.
Case Management and Decision Making
- Case management coordinates healthcare services across all levels of care, streamlining costs and maintaining quality.
- Decision making involves shared governance, responsibility, autonomy, authority, accountability, and staff involvement.
Interprofessional Collaboration and Rounding
- Interprofessional collaboration occurs among nurses and healthcare providers, aiming to deliver quality, safe patient care and create a positive work culture.
- Interprofessional rounding encourages patient and family involvement in planning care, promoting coordination and communication among the healthcare team.
Head to Toe Assessment and Prioritizing Care
- Head to Toe assessment leads to prioritizing care and making clinical judgments.
- Clinical judgment is the observed outcome of critical thinking and decision making.
Critical Thinking and Clinical Judgment
- Clinical judgment involves observing outcomes, making decisions, and taking action.
- Technicians or assistive personnel cannot make decisions or take immediate action.
Reflection and Competent Communication
- Reflection involves visualizing a situation, reviewing, and learning from it.
- Competent communication maintains effective relationships, meeting legal, ethical, and clinical standards of care within the entire sphere of professional practice.
Types of Communication
- Therapeutic communication occurs within a healing relationship between a nurse and patient.
- Intrapersonal communication is self-talk, a powerful form of communication that helps nurses relate to others.
- Interpersonal communication is one-on-one interaction between a nurse and another person, occurring face-to-face or via text or electronic format.
Critical Thinking and Overcoming Biases
- Critical thinking applied during patient interactions helps overcome perceptual biases or stereotypes that interfere with accurately perceiving and interpreting messages.
Circular Transactional Model of Communication
- The circular transactional model includes the referent, sender, receiver, message, channels, context or environment, feedback, and interpersonal variables.
Verbal Communication
- Vocabulary, denotative and connotative meaning, pacing, intonation, clarity, and brevity are essential for effective verbal communication.
- Timing and relevance are critical for effective communication.
Metacommunication and Motivational Interviewing
- Metacommunication refers to all factors that influence communication.
- Motivational interviewing encourages patients to share their thoughts, goals, beliefs, fears, and concerns.
Nurse-Family Relationships and Nurse-Health Care Team Relationships
- Nurse-family relationships require forming caring relationships with entire families in community and home care settings.
- Effective communication with the healthcare team affects patient outcomes, patient safety, and the work environment.
Communication Techniques and Lateral Violence
- SBAR technique is used for communicating critical information.
- Lateral violence, or bullying, between colleagues can occur and negatively impact communication.
Therapeutic and Nontherapeutic Communication Techniques
- Therapeutic communication techniques encourage the expression of feelings and ideas and convey acceptance and respect.
- Nontherapeutic techniques discourage further expression of feelings and ideas and engender negative responses.
Sociocultural Considerations and Speech and Language
- Culture influences thinking, feeling, behaving, and communicating.
- Speech and language considerations are essential for effective communication.
Patient Outcomes and Evaluation
- Patient outcomes are influenced by various factors, including communication techniques and cultural considerations.
- Evaluation involves determining a patient's perception of the success of the plan of care and modifying the plan as needed.
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Description
This quiz covers the importance of documentation in healthcare, including its purposes and benefits for patient care and interprofessional communication.