COMMUNICATION &
DOCUMENTATION
NUR-102 SPRING 2015
BELINDA LOWRY, MSN, RN, CCRN
TICKET TO ENTRY
• https://www.corexcel.com/courses/Documentation
-Web-Handout.pdf
• Print test, complete, and bring to class on day of
lecture.
GOOD MORNING!
COMMUNICATION
• Essential part of patient-centered care
• Effective communication helps prevent errors and
injuries, and ensures high-quality patient care
• Maintains effective relationships
COMMUNICATION
INTERPERSONAL RELATIONSHIPS
• Nurse-patient relationship is a partnership with equal
participants
• Being attentive to the patient will improve the
likelihood that patient’s needs are being met
• Body language just as important as verbal
language
COMMUNICATION SKILLS
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Critical thinking promotes effective communication
Self-confidence can reassure the patient
Fairness and integrity
Humility
FORMS OF COMMUNICATION
• Verbal
• Vocabulary
• Denotative &
connotative
• Pacing
• Intonation
• Clarity & brevity
• Timing & relevance
• Nonverbal
• Personal
appearance
• Posture & gait
• Facial expression
• Eye contact
• Gestures
• Sounds
• Territoriality &
personal space
ELEMENTS OF PROFESSIONAL
COMMUNICATION
Courtesy
Use of names
Trustworthiness
Autonomy &
Responsibility
• Assertiveness
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NONTHERAPEUTIC TECHNIQUES
• Asking personal
questions
• Giving personal
opinions
• Changing the
subject
• False reassurance
• Arguing
• Sympathy
• Asking for
explanations
• Approval or
disapproval
• Defensive, passive,
or aggressive
responses
NONTHERAPEUTIC COMMUNICATION
https://www.youtube.com/watch?v=W
1RY_72O_LQ
THERAPEUTIC TECHNIQUES
• Active Listening
• Sharing
observations
• Sharing empathy
• Sharing hope
• Sharing humor
• Sharing feelings
• Using touch
• Clarifying
• Asking relevant
questions
• Summarizing
• Paraphrasing
• Self-disclosure
NCLEX PRACTICE
The nurse has a patient who is short of breath and
calls the health care provider using SBAR to help
with the communication. What does the nurse first
address?
A. The respiratory rate is 28.
B. The patient has a history of lunch cancer.
C. The patient is short of breath.
D. He or she requests an order for a breathing
treatment.
NCLEX PRACTICE
The statement that best explains the role of
collaboration with others for the patient's plan of
care is which of the following?
A. The professional nurse consults the health
care provider for direction in establishing goals for
patients.
B. The professional nurse depends on the latest
literature to complete an excellent plan of care for
patients.
C. The professional nurse works independently
to plan and deliver care and does not depend on
other staff for assistance.
D. The professional nurse works with colleagues
and the patient's family to provide combined
expertise in planning care.
NCLEX PRACTICE
Identify behaviors that foster the development of
trust. (Select all that apply.)
A. Turning on the TV to her favorite show.
B. Pulling the curtain to provide privacy.
C. Offering to discuss information about her
condition.
D. Asking her why she is crying.
E. Sitting quietly by her bed and holding her
hand.
BREAK
DOCUMENTATION
• Proof of patient actions &
activities
• Must be accurate,
comprehensive, complete,
and true
• Illustrates quality of care the
patient received
• Helps facilitate
communication among the
health care team
CONFIDENTIALITY
• All patient information is confidential
• HIPAA: Health Insurance Portability and
Accountability Act
• Only those who have a direct need to access a
record may do so
• Cannot access your family, your own, your friends’, your
coworkers’
• No pictures, no social media
• Works both ways
• Patient has a right to limit any and all information
given out
• Passwords, code words, “Jane/John Doe” pseudonyms
BLOG, JUNE 3, 2013
Patient John Smith, 123 Candy Lane, was in out clinic
today. He turned 63 yesterday and is complaining of
chest pain. He admits to not taking his blood pressure
medication regularly and to poor management of his
diabetes. We are so frustrated!
BLOG, JUNE 3, 2013
We saw one of our patients today in clinic. We know
him well, as he also delivers for the Jimmy Johns on
Main Street. He turned 63 yesterday and now has
chest pain. He admits to not taking his BP meds
regularly and to not managing his diabetes as
instructed.
BLOG, JUNE 3, 2013
I am so frustrated with some of our patients. Take the
person I saw today. I have spent so much time trying
to help this person but she just won’t follow my
advice. She is forgetful about taking her medications
and won’t try any ideas for improving that situation.
People, listen to your nurse!
BLOG, JUNE 3, 2013
(FROM A DERMATOLOGIST)
Check out this link. (link). This is a great news story on
CNN about one of our patients, talking about what it
is like to battle leukemia. He has been our patient for
many years. It is great to hear his positive statements
about surviving long term with cancer.
PURPOSES OF RECORDS
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Communication
Reimbursement
Education
Research
Auditing & monitoring
GUIDELINES
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Factual
Accurate
Complete
Current
Organized
METHODS OF DOCUMENTATION
• Paper & Electronic Health
Records (EHR)
• Narrative
• Problem-oriented
• SOAP
• Subjective, Objective, Assessment,
Plan
• PIE
• Problem, Intervention, Evaluation
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Charting by exception
Flow sheets/charts
Kardex & Patient Summary
Standardized care plans
REPORTING
• Hand-off report
• Shift report, any transfer of care
• Telephone report & orders
• Incident report
• SBAR
• Situation, Background, Assessment, Recommendation
BOX 26-4: GUIDELINES FOR TELEPHONE
& VERBAL ORDERS
• • Clearly determine the patient's name, room number,
and diagnosis.
• • Repeat any prescribed orders back to the physician or
health care provider.
• • Use clarification questions to avoid misunderstandings.
• • Write TO (telephone order) or VO (verbal order),
including date and time, name of patient, the complete
order; sign the name of the physician or health care
provider and nurse.
• • Follow agency policies; some institutions require
telephone (and verbal) orders to be reviewed and
signed by two nurses.
• • The health care provider must co-sign the order within
the time frame required by the institution (usually 24
hours).
TIPS
• Base your documentation on your objective assessment
findings using your senses of sight, touch, hearing, and
smell.
• Document at the same time as the intervention if you
can, or as close to it as possible.
• Beware of the following shortcomings in documentation
that could allow an attorney to raise questions about the
quality of care you gave the patient.
• Don't leave space so you can add more documentation
later.
• Keep your personal opinions out of the record. However,
without editorializing, you should factually and
objectively document the patient's behavior (including
any failure to adhere to treatment) if it's relevant to his
care.
NCLEX PRACTICE
You are supervising a beginning nursing student
who is documenting patient care. Which of the
following actions require you to intervene? The
nursing student:
A. Documented medication given by another
nursing student
B. Included the date and time of all entries in
the chart.
C. Stood with his back against the wall while
documenting on the computer
D. Signed all documents electronically.
NCLEX PRACTICE
A patient asks for a copy of her medical record. The
best response by the nurse is to:
A. State that only her family may read the
record.
B. Indicate that she has the right to read her
record.
C. Tell her that she is not allowed to read her
record.
D. Explain that only health care workers have
access to her record.
NCLEX PRACTICE
Put the following entries in the correct order as they
pertain to a SOAP note.
A. Repositioned patient on right side.
Encouraged patient to use patient-controlled
analgesia (PCA) device.
B. “The pain increases every time I try to turn on
my left side.”
C. Acute pain related to tissue injury from
surgical incision.
D. Left lower abdominal surgical incision, 3
inches in length, closed, sutures intact, no
drainage. Pain noted on mild palpation.
DOCUMENTATION
EXERCISE
David Page, an 80-year-old man, is admitted to the
hospital with a diagnosis of possible pneumonia. He
states that he is not feeling well and has a frequent
productive cough, which is worse at night. Vital
signs are: blood pressure, 150/90 mm Hg; pulse rate,
92 beats/min; respirations, 22 breaths/min. During
your initial assessment he coughs violently for 40 to
45 seconds. His lungs have wheezes and rhonchi in
both bases and are otherwise clear. He states, “My
chest hurts when I cough, and the pain radiates into
my arm.”