Health Communication in Healthcare

Questions and Answers

What is the primary purpose of documenting a client's condition and care?

To provide legal protection to the nurse

What should be included in a telephone report?

The date and time of the report, the name of the person giving the information, and the subject of the information

What is the purpose of using the SBAR tool in reporting?

To communicate effectively with other members of the healthcare team

Why is it important for nurses to read the nurses' notes prior to care?

To determine if there has been a change in the client's condition Signup and view all the answers

What is the primary focus of recording nursing actions?

To show that follow-up actions were taken Signup and view all the answers

Why is conciseness important in recording?

To avoid elaborating on background data or routine care Signup and view all the answers

What should be included in a summary of newly admitted clients?

The client's health problems, care transferred, and discharged from the unit Signup and view all the answers

Why is it important to document all assessments, nursing interventions, and client responses?

To ensure continuity of care and provide legal protection Signup and view all the answers

What should be done when receiving a telephone report?

Repeat the message back to the sender to ensure accuracy Signup and view all the answers

Why is it important to prioritize care?

To ensure that the client receives necessary care Signup and view all the answers

Study Notes

Communication in Healthcare

Communication is essential for different health professionals to interact with a client and prevent fragmentation, repetition, and delays in client care.
It helps the client to expand or develop a topic of importance and enables them to explore their ideas and feelings about a situation.

Documenting and Reporting

Documenting client progress involves recording and documenting client's progress, using a multidisciplinary approach to planning and delivering quality, cost-effective care within an established length of stay.
Critical pathways are used to document client care, emphasizing quality, cost-effective care.

Key Principles of Documenting

Legibility: Ensure documentation is easy to read to prevent misinterpretation.
Permanence: Use dark ink to ensure the record is permanent.
Accepted terminology: Use only commonly accepted abbreviations, symbols, and terms specified by the agency.
Completeness: Record all assessments, nursing interventions, client problems, comments, and responses to interventions.
Conciseness: Recordings need to be brief and complete.
Legal prudence: Accurate, complete documentation gives legal protection to the nurse.

Admission Nursing Assessment

Also referred to as an initial database, nursing history, or nursing assessment.
Can be organized according to health patterns, body systems, or health problems and care.

Telephone Report

When receiving a telephone report, document the date and time, the name of the person giving the information, and the subject of the information received.
Repeat the message back to the sender to ensure accuracy.

DOS and DON'TS in Recording

DO: Chart a change in the client's condition, read the nurses' notes prior to care, and record all nursing actions on time.
DON'T: Elaborate on background data or routine care, report coming and going of visitors, and don't repeat information already documented.

SBAR Tool

S: Situation - state your name, unit, client name.
B: Background - medical diagnosis, date of admission, pertinent information.
A: Assessment - briefly state the problem.
R: Recommendation - state the priority of care that is due after the shift begins.