CHAPTER 3 (1).pdf

CHAPTER 3: COMMUNICATION IN HEALTHCARE MDM. NUR-AZZAH BINTI SALEH  INTRODUCTION As a healthcare manager, strength communication determine the overall performance effectiveness. Savvy managers can improve communications by: Focusing the mutual benefits...

CHAPTER 3: COMMUNICATION IN HEALTHCARE MDM. NUR-AZZAH BINTI SALEH  INTRODUCTION As a healthcare manager, strength communication determine the overall performance effectiveness. Savvy managers can improve communications by: Focusing the mutual benefits Tailoring their messages Active listening Using the effective technique in communication Proactive managers can respond effectively to conflicts and often improving situations  Understanding the communication process Communication essentials Communication is an interpersonal process of sending and receiving symbols with messages to attached to them Effective communication the intended message of the sender and the interpreted meaning of the receiver are one the same. Although this may seem like the goal in any communication attempt, it is not always achieved Efficient communication A minimum cost in terms of resources expended, such as the amount of time involved. It is one of the main reason people like to rely on voice mail and email rather than visiting other personally to communicate. THE PROCESS OF INTERPERSONAL COMMUNICATION  COMPONENTS OF COMMUNICATION COMPONENTS DESCRIPTION People Process in the roles as both sources and receivers Source A message initiator Receiver A message target Message The verbal or nonverbal form of the idea, thought or feeling that one person (the source) wishes to communicate to another person or group of people (the receiver) Channel The means by which a message moves from the source to the receiver of the message Feedback The receiver’s verbal and non verbal response to the source’s messages. COMPONENTS DESCRIPTION Code A systematic arrangements of symbols used to create meanings in the mind of another person or persons. Verbal Codes Symbols and their grammatical arrangement, such as languages All symbols that are not words, including bodily movements, Nonverbal Codes use of space and time clothing and adornments and sounds other than words. Encoding The process of translating an idea or thought into a code Decoding The process of assigning meaning to the idea or thought in a code Noise Any interference in the encoding and decoding processes that reduces message clarity  WRITTEN COMMUNICATION Communication by means of written symbols that communicated by or two or between people of groups. Hence, written communication is the presentation of ideas or essays with clear points, supplying the details of supporting point demonstrate unity coherence of thoughts. ELEMENTS OF WRITTEN COMMUNICATION STRUCTURE STYLE (the way the (the way it is content is laid out) written) CONTENT (what you are writing about) COMPONENT OF WRITTEN COMMUNICATION VALIDITY AUDIENCE (What you say should (Write in a way that a be true and should classmate could follow follow logically) what you write) STRUCTURED (It should be clear what information you are starting with and what you are trying to find.) 3 IMPORTANT STAGES OF WRITTEN WORK EDITTING PLANNING ORGANIZING WRITING REVISING STAGE STAGE STAGE STAGE THE WRITTEN DOCUMENT SHOULD HAVE EFFICIENT EFFECTIVENESS EQUITY  Confusing Language AVOID Information FOUR Verbosity Overload COMMON ERRORS Poor Sentence Structure  COMPUTER AND TECHNOLOGY IN HEALTHCARE Computers have revolutionized the way medication is administered and diagnosing medical treatment required. With access to accurate patient records, doctors and nurses can review an individual's full medical history in detail, enabling them to diagnose, treat, and administer medications in a timely manner. USES COMPUTER IN HEALTHCARE Medical Medical and Patient Imaging and Patient Data Monitoring Equipment Communication Research and Inventory Telemedicine  DOCUMENTATION IN MEDICAL RECORD Medical record is all of the written documentation relating to a patient. It includes past history information, current diagnosis and treatment and correspondence relating to the patient. Billing information is often maintained in a separate accounting record. Medical record is a legal document. Various laws cover the reporting, disclosure and confidentiality of medical records. Medical records management requires attention to accuracy, confidentiality and proper filing and storage. The medical records may be subpoenaed, ordered by court, during a malpractice case. PURPOSE OF THE MEDICAL RECORD Serves multiple purposes Provide a medical picture and record of the patient from birth to death An important document for the continual managements of the patient’s healthcare and furnishes documentary evidence of the course of evaluation and treatment. It can assisting the physician in diagnosing, treating and tracking the patterns of the patient’s health. Provide data and statistics on health matters such as birth, death, communicable diseases CONTENTS OF MEDICAL RECORDS It contains both personal information about the patient and medical or clinical notations supplied by the physician and other healthcare professionals caring for the patients. PERSONAL PATIENTS THE CLINICAL DATA INFORMATION INFORMATIONS Full name Medical Examination Addressed X-Rays Telephone number Laboratory reports DOB Consent forms Marital status Employer Insurance Information  EXAMPEL OF PERSONAL PATIENT INFORMATION  EXAMPEL OF CLINICAL DATA INFORMATION CORRRECTIONS AND ALTERATIONS DO’S DON’TS Drawing a single line through the error Writing the correction above the error Do not erase or use corrections fluid Dating the changes Initialing it The original statement or error never be obliterate  TIMELINESS OF DOCUMENTATION All entries should be made as they occur or as soon as possible afterward The reports should be completed within 30 days following patient’s discharge from a hospital. INCOMPLETE occur when the record late into the medical chart. It will rise the problem if the record is involve in subpoenaed for a malpractice suit. Moreover, any entry made into a medical record after a lawsuit is threatened or files is suspect. Plus, if the medical is not updated promptly, there could be a lapse of memory about what actually occurred.  COMPLETENESS OF ENTRIES If the medical record is incomplete , the physician or other healthcare provider may be unable to defend allegations of malpractice, even if there was no negligence. CREDIBILITY OF THE MEDICAL RECORD One physician may be asked by attorney to review a medical record pertaining to a medical malpractice case of another physician to help determine if there is evidence of malpractice The physician will e looking for gaps or other problem record such as illegible handwriting, delays in placing x-ray and laboratory reports into the file, altered records or any contrived or invented documentation. It been examined during Medicare Medicaid fraud cases whereby a physician has falsely claimed payment for services that were never rendered. CONFIDENTIALITY AND THE MEDICAL RECORD Personal Data Release of Protection Act Information (PDPA) 2010 Health Insurance Portability and Accountability Act 1996 (HIPAA)  RETENTION AND STORAGE OF MEDICAL RECORDS. Physical Storage Backup Storage Cloud Storage Digital Storage Backup Storage Patient Portals  TUTORIAL 1 2 1. By using the framework of the elements in communications process, describe the picture (1) besides. (must include the dialogue) 2. List all the components in communications 3. Based on the 2nd picture, write an essay of the advantage of social media (socmed) in healthcare institution. The essay must include the elements of written communication. 4. Explain the use of the computer in healthcare industry. 5. As the healthcare worker, how do you provide the medical record in court?