Medical Tech Prep 1
Lancaster High School
Mrs. Carpenter
Chapter 6: Communicating with the Health Team
OBJECTIVES
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Define the key terms listed in this chapter
Explain why health team members need to communicate
Describe the rules for good communication
Explain the purpose, parts, and information found in the
medical record
Describe the legal and ethical aspects of medical records
Describe the purpose of the Kardex
List the information you need to report to the nurse
List the basic rules for recording
Use the 24-hour clock, medical terminology, and
abbreviations
Explain how computers are used in health care
Explain how to protect the right to privacy when using
computers
Describe the rules for answering phones
Explain how to deal with conflict
COMMUNICATION
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Communication is the exchange of
information.
A message sent is received and
interpreted by the intended person.
For good communication:
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Use words that mean the same thing to
the sender and the receiver of the
message.
Use familiar words.
Be brief and concise.
Give information in a logical and orderly
manner.
Give facts, and be specific.
APPLICATION :BACKART
THE MEDICAL RECORD
(CHART)
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a written account of a person’s
condition and response to treatment
and care.
The health team can share
information
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permanent.
legal document.
Contains many forms.
Each page stamped with
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person’s name
room number
other identifying information.
THE MEDICAL RECORD
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includes:
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Admission sheet
Nursing history
Physical examination results
Doctor’s orders
Progress notes
Graphic sheet
Flow sheets
Laboratory results
X-ray reports
IV therapy record
Respiratory therapy record
Consultation reports
Surgery and anesthesia reports
Other reports (e.g., physical, occupational, and
speechtherapies)
Special consents
THE MEDICAL RECORD
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Agency policies about medical
records address:
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Who records
When to record
Abbreviations
Correcting errors
Ink color
Signing entries
Some agencies allow nursing assistants
to record.
THE MEDICAL RECORD
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Professional staff involved in a
person’s care can look at the chart.
Some agencies let nursing
assistants read charts.
ethical and legal duty to keep
information confidential.
Many agencies let patients and
residents see their records
If a patient or another person asks to
see a medical record, report the
request to the nurse.
The Admission Sheet
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completed when the person is
admitted
has identifying information about the
person.
The name of the person’s nearest
relative or legal representative is
included.
An identification (ID) number is given
and recorded on the admission
sheet.
advance directives are recorded
used to fill out other forms
Nursing History
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completed when the person is admitted.
contains information about:
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chief complaint
History of the current illness
Childhood illnesses
Past health problems, surgeries, and injuries
Current drugs
Allergies
Family health history
Lifestyle
Problems with activities of daily living
Education and occupation
The Graphic Sheet
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used to record measurements
and observations
made every shift or 3 to 4 times
a day.
Dependent on facility policy
Progress notes
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describe the care given and the person’s response.
The nurse records:
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signs and symptoms
Information about special treatments and drugs
Information about patient or resident teaching and
counseling
Procedures performed by the doctor
Visits by other health team members
Focus on long-term care: progress notes
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Interdisciplinary progress notes are used in long-term
care.
Daily recordings are not necessary.
Center policies state how often recordings are made.
OBRA requires a written summary every 3 months.
Flow sheets
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used to record frequent
measurements or observations.
Some are designed to record
frequent vital signs.
intake and output record is a type
flow sheet
Focus on long-term care: flow sheets
An activities of daily living (ADL) flow
sheet is common in long-term care.
THE KARDEX
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a card file that summarizes
information found in the medical
record.
a quick, easy source of
information about the person
Used frequently in long-term
care
REPORTING AND
RECORDING
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The health team communicates by reporting and
recording.
Reporting
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report care and observations to the nurse.
Practice the following rules:
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the oral account of care and observations.
Be prompt, thorough, and accurate.
Give the person’s name and room and bed number.
Give the time your observations or care was given
Report only what you observed or did yourself.
Give reports as often as the person’s condition
requires.
Or as often as the nurse asks you to do so.
Report any changes from normal or changes in the
person’s condition at once.
Use your written notes to give a specific, concise,
and clear report.
REPORTING AND RECORDING
End-of-shift report
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Given at the end of the shift to
the oncoming shift
Information given
care given
 care that must be given
 person’s condition
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Nursing assistants attend
dependent on agency policy
Recording
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the written account of care and
observations.
Box 5-1 on page 63
your charting should show:
What you observed
 What you did
 The person’s response
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APPLICATION
RECORDING OBSERVATIONS
Recording -Recording Time
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The 24-hour clock (military time
or international time)
has four digits
 No am or pm
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Box 5-2 on page 64
Communication is better with
the 24-hour clock
Application
Military Time Worksheet
Abbreviations
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shortened forms of words or
phrases.
accepted abbreviations differ
from agency to agency
Obtain the list when you are hired.
 Use only abbreviations accepted
by the agency.
 If you are unsure, write the term
out in full.
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USING COMPUTERS
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Computer systems collect, send, record, and store
information.
Many agencies store charts and care plans on
computers.
The health team uses computers to send messages
and reports to the nursing unit.
Uses
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measurements such as blood pressures
Temperatures
heart rates
heart function monitoring.
Doctors can use computers
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when diagnosing.
to prescribe drugs.
USING COMPUTERS
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Advantages
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Disadvantages
PHONE COMMUNICATIONS
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Good communication skills are
needed.
information is given by
Words
 your tone of voice
 how clearly you speak
 your attitude
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PHONE COMMUNICATIONS
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Be professional and courteous.
Practice good work ethics.
Follow the agency’s policy.
Box 4-5 on page 67
Focus on home care: phone
communications
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When answering phones in patient homes,
simply say “hello.”
Saying that you are a home health assistant tells
the caller that an ill, older, or disabled person is
in the home.
Do not give your name or the person’s name
until you know who is calling and why.
Make sure the caller is someone you want to
talk to.
DEALING WITH CONFLICT
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a clash between opposing
interests and ideas.
arise over issues or events.
The problems must be worked
out for good productivity at the
work site.
DEALING WITH CONFLICT:
problem-solving process
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involves the following steps:
Step 1: Define the problem.
 Step 2: Collect information about
the problem.
 Step 3: Identify possible solutions.
 Step 4: Select the best solution.
 Step 5: Carry out the solution.
 Step 6: Evaluate the results.
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DEALING WITH CONFLICT
guidelines
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can help you deal with conflict:
Ask your supervisor for some time to
talk privately.
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Explain the problem.
Give facts and specific examples.
Ask for advice in solving the problem.
Approach the person with whom you
have a conflict.
Ask to talk privately.
Agree on a time and place to talk.
DEALING WITH CONFLICT
guidelines con’t
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Explain the problem.
Listen to the person.
Identify ways to solve the problem.
Set a date and time to review the
matter.
Thank the person for meeting with
you.
Carry out the solutions.
CROSS-TRAINING
OPPORTUNITIES
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You may be asked to cross-train
for other roles.
You will have greater job
options.
You will learn more about what
these workers do.
APPLICATION
Care Planning Considerations
Nurses Notes
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