APPLIED EDUCATIONAL SYSTEMS
Communications
Health Science and Technology Education
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APPLIED EDUCATIONAL SYSTEMS
Health Science
TABLE OF CONTENTS
Communications
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Explore Go
Communication (Lessons 1-3) Go
Interpersonal Communication (Lessons 4-7) Go
Communication Barriers (Lessons 8-12) Go
Patients (Lessons 13-15) Go
Documentation (Lessons 16-18) Go
Communication Technology (Lessons 19-21) Go
Reflect Go
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APPLIED EDUCATIONAL SYSTEMS
Health Science
Explore
 Unit Overview Go
 Activity Go
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APPLIED EDUCATIONAL SYSTEMS
Health Science
Explore – Unit Overview
In this unit, you will:
 Discover the
communication process.
 Explore communication
barriers and what health
care workers can do to
avoid barriers.
 Examine several types of
documentation.
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APPLIED EDUCATIONAL SYSTEMS
Health Science
Explore - Activity
You will participate in a communication activity
according to your teacher’s instruction.
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APPLIED EDUCATIONAL SYSTEMS
Health Science
Communication
 1. Types of Communication Go
 2. Communication Process Go
 3. Quiz Go
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APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 1 – Communication in Health Care
 Communication is the
process of exchanging
messages.
 Health care professionals
must communicate
effectively and appropriately
with other health care
workers, patients and clients
and their families, students,
visitors, administrators, and
business contacts.
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APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 1 – Verbal Communication
 Verbal communication is the use
of language and words to send
and receive information.
 Verbal communication is the
form people use most often. It is
also the most effective.
 Goals for verbal communication:
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Establish rapport
Obtain information from patients
Confirm understanding
Relay information to other
health care workers
▫ Give instructions to patients
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APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 1 – Tone of Voice
 A speaker’s feelings are
expressed through tone of
voice.
 Patients can easily pick up on
fear, agitation, calmness, and
confidence from a health care
worker’s volume, rate, and
pitch.
 If health care workers can
adjust their tone of voice
appropriately to the situation, it
can become an effective
communication tool.
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APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 1 – Language Choice
 When interacting with patients,
health care workers must
translate medical terminology
into lay terms.
 At the same time, health care
workers must avoid talking
down to patients by oversimplifying their language.
 They should also be careful to
enunciate words and avoid
mumbling.
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APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 1 – Written Communication
 Written communication is a
form of verbal communication.
 Written communication allows
the writer time to research and
to organize thoughts.
 Written communication must:
▫ Be accurate and clear
▫ Be brief with logical
organization
▫ Be free of grammar, spelling,
and punctuation errors
▫ Use appropriate vocabulary
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APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 1 – Selecting the Correct Form
 Before using written communication,
health care workers must first ask
themselves if the message would be
better delivered orally.
 They should also decide whether or
not the message requires a written
record.
 Then, the health care workers must
decide what format the message
should take – letter, email, report,
etc.
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APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 1 – Writing Memos
 Memos are a form of written
communication that are often
used in the health care industry.
 Memos have standard parts:
▫ TO: the names of the people for
whom the memo is intended.
▫ FROM: the name of the person
sending the memo.
▫ DATE: the date the memo is
created.
▫ SUBJECT: the purpose of the
memo.
▫ The body of the memo includes
the details of the message.
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APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 1 – The Five W’s
1. Who is the audience?
2. What is the purpose of
the message?
3. Why is the message
important?
4. When did or will the event
occur?
5. Where did or will the
event take place?
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APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 1 – Nonverbal Communication
 Nonverbal communication
includes methods used in
addition to or as a substitute for
language.
 Nonverbal communication
includes the following methods:
▫ Eye contact and facial
expressions
▫ Gestures and body language
▫ Physical appearance
▫ Touch
▫ Proximity
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APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 1 – Eye Contact and Facial Expressions
 Eye contact is one form of
facial expression. Direct eye
contact usually sends a
powerful and positive message.
 Smiles and other facial
expressions communicate
messages.
 Health care workers must be
conscious of both interpreting
facial expressions in others and
in mastering their own
expression to be sure that they
are sending the appropriate
message.
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APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 1 – Gestures and Body Language
 Body language sends powerful
messages to others. At times,
people use their bodies instead
of words, such as when
someone nods or shakes the
head.
 Posture also conveys a
message.
 Health care workers must be
skilled both in reading and in
using gestures and body
language effectively.
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APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 1 – Physical Appearance
 In the health care industry,
many workers wear uniforms.
Their uniforms send the
message that they belong to
the health care field.
 In addition to uniforms, physical
appearance is also expressed
by grooming.
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APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 1 – Touch
 Touch can communicate
many things.
 Touch can also be
misinterpreted, which can be
a serious matter. health care
workers must always be
conscientious to touch
patients with only kindness
and respect.
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APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 1 – Proximity
 Proximity refers to the physical
space between people.
 Proximity includes:
▫ Distance between people
▫ Height
▫ Odor
 Health care workers must often
invade patients’ personal space
in order to perform their duties.
Sensitivity and professionalism
are required when patient
proximity is an issue.
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APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 2 – Communication Process
 Communication is a process.
 The sender-receiver model is
a way to break down the
process into steps.
 This model can be used
together with active listening
skills to create effective
communication.
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APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 2 – Sender-Receiver Model
 The sender is the person
who encodes, or gives,
information.
 The receiver is the person
who decodes, or accepts, the
information.
 The message is the
information that is being
communicated.
 Other elements include
frame of reference and
feedback.
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APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 2 – Active Listening Skills
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Show interest.
Be alert.
Maintain eye contact.
Avoid interrupting.
Pay attention.
Avoid thinking ahead for a
response.
Try to ignore personal
prejudices.
Ignore distractions by moving to
a quiet place.
Watch the speaker closely for
nonverbal contradictions.
Maintain a positive attitude.
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APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 2 – Restatement, Reflection, and Clarification
 Restatement involves repeating
the message back to the sender
in the receiver’s own words.
Restatement verifies that the
correct message has been
heard and understood.
 Reflection involves responding
with empathy.
 Clarification occurs when the
receiver asks questions to get a
more concise explanation or to
clear up any confusion about
the message.
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APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 2 – Other Effective Communication Skills
 Be conscious of your own
body language, including
posture and eye contact.
 Avoid any display of
anger.
 Speak slowly, softly, and
clearly.
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APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 3 – Quiz
In this lesson, you will take a quiz on types of
communication and communication processes.
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APPLIED EDUCATIONAL SYSTEMS
Health Science
Interpersonal Communication
 4. General Guidelines
Go
 5. Group Communication
 6. Directions
 7. Quiz
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APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 4 – Attitudes and Behaviors
 Successful communication
requires that people adopt
acceptable attitudes and
behaviors.
 Attitudes and behaviors
that are critical to
successful communication
include courtesy, respect,
sensitivity to boundaries,
and empathy.
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APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 4 – Courtesy
 Courtesy involves being
polite, gracious, helpful, and
considerate.
 Everyone has a bad moment
or even a bad day now and
then. However, it is
important to overcome
personal and other issues
unrelated to the job and to
focus on performing the
work at hand with courtesy.
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APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 4 – Respect
 Respect is to approach
another person with a
feeling of esteem or regard.
 Respect is an overriding
theme in any study of
communication in health
care.
 Without proper respect,
communication can quickly
veer towards failure.
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APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 4 – Sensitivity to Boundaries
 Sensitivity is the ability to
see and appreciate the
personal traits of others.
 Specifically, sensitivity to
boundaries is the ability to
recognize and observe the
emotional and physical
limits of others.
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APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 4 – Empathy
 Empathy is the ability to
share in someone else’s
feelings or emotions.
 Patients who are lonely or
facing serious surgeries or
terminal illnesses are in
special need of empathy.
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APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 4 – Diversity
 When dealing with people who are
different from themselves, health
care workers must put aside all
personal and cultural bias.
 Health care workers must treat all
people fairly, equally, and with
sensitivity.
 Health care workers must be
aware that others have cultural
and personal biases, as well.
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APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 4 – Diversity (continued)
 Diversity includes the following:
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Race
Gender
Age
Ethnicity
Socioeconomic status
Occupation
Health status
Religion
Sexual orientation
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APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 4 – Criticism
 Constructive criticism can
build people up and inspire
them to do better.
 Non-constructive criticism
serves only to tear people
down and discourage them.
 Health care workers must be
prepared to both accept and
give constructive criticism.
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APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 4 – Accepting Constructive Criticism
 When people receive
constructive criticism, they
should appreciate it.
 People who receive
criticism should avoid
making excuses, getting
angry, and blaming others.
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APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 4 – Giving Constructive Criticism
 When giving criticism, people
should put themselves in the
other’s place.
 They should choose their
words carefully and speak
kindly and considerately and
allow the other person a
moment to accept what they
are saying.
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APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 5 – Group Communication
 Health care workers must
effectively communicate with their
colleagues.
 Health care workers must put
aside all personal prejudice and
treat team members fairly and
equally and so that they can
communicate effectively in group
situations.
 Successful group situations also
involve an understanding of
communication patterns,
interaction, and participation.
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APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 5 – Communication Patterns
 A chain-of-communication
pattern starts at the top of the
organization and then flows down
to the bottom.
 A wheel-of-communication
pattern has a central hub where
the information originates. This
hub gives the information to all
the spokes of the wheel.
 An all-channel communication
pattern allows for small
departments or groups to
distribute information to all other
groups, and vice versa.
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APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 5 – Group Interaction
 Conformity occurs when
individuals change their opinions
or beliefs to match that of the
group.
 In some instances, conformity
can be bad, as it may cause
people to go against their beliefs
and values.
 In the professional world,
conformity can be good. It is
good when people conform to
behave appropriately in the
professional atmosphere.
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APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 5 – Group Participation
 To participate effectively in a
group, people need to
understand the group goals and
their own roles within the group.
 In meeting situations, group
members must:
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Be prepared.
Use active listening skills.
Focus on the discussion.
Share relevant ideas.
Respect others.
Follow through with
assignments.
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APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 6 – Directions
 In the health care field, it
is critical that directions
are carried out correctly.
 In order for this to occur,
directions must both be
given and taken
accurately.
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APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 6 – Giving Directions
 When giving directions, health care
workers should:
▫ Keep instructions simple and brief.
▫ Give directions in a logical,
chronological order.
▫ Always adjust their language and
the complexity of directions
according to the patient’s ability to
comprehend.
▫ Have the patient restate the
process to ensure that a patient
understands.
▫ Correct any misunderstanding.
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APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 6 – Following Directions
 When following directions, health
care workers must:
▫ Be diligent in paying close
attention to directions
▫ Ask questions until they fully
understand what is expected of
them if the instructions are
unclear.
▫ Take notes so that they can
remember not only to perform the
task, but the key instructions for
carrying it out.
▫ Be certain to follow through with
the directions at the appropriate
time and place.
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APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 7 – Quiz
In this lesson, you will take a quiz on
interpersonal communication.
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APPLIED EDUCATIONAL SYSTEMS
Health Science
Communication Barriers
 8. Personal Barriers Go
 9. Cultural Barriers Go
 10. Physical Barriers Go
 11. Environmental Barriers Go
 12. Quiz Go
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APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 8 – Communication Barriers
 There are many things that can
interfere with effective
communication.
 A communication barrier can
make it difficult for someone to
send a clear message,
understand the message being
sent, or provide appropriate
feedback.
 Communication barriers can be
environmental and personal. And
they can be caused by physical
disabilities, psychological issues,
and cultural diversity.
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APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 8 – Personal Communication Barriers
 Personal barriers can occur within
either participant in communication.
 They can result from emotions and
attitudes, resistance to change,
preconceptions, and self-absorption.
 Personal barriers can form out of
prejudice and personality, including
traits such as closed-mindedness,
judging, belief in stereotypes, and
preaching or moralizing.
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APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 8 – Emotions and Attitudes
 Extreme emotions, good and
bad, can interfere with a person’s
ability to concentrate on a
conversation.
 Personal attitudes can also
create barriers. These attitudes
may include:
▫ Prejudice
▫ Selective comprehension
▫ Complacency
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APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 8 – Preconceptions
 Preconceptions are similar to
prejudice.
 Preconceptions are typically
directed toward to a single
person, rather than a group.
 Preconceptions create barriers
when people disregard what
another is saying simply
because they disagree or they
do not care for the other person.
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APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 8 – Resistance to Change
 Health care workers may have
resistance themselves, or they
may have to deal with a patient’s
resistance. Either way, it must be
overcome.
 Health care workers must be
flexible and open-minded
towards changes in procedures
that can improve health care for
patients.
 Likewise, they must become
skilled at communicating the
benefits of change in a positive
way to patients that reject new
ideas.
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APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 8 – Self-Absorption
 When people are preoccupied
with their own problems,
schedules, day-dreaming, and
other issues, they can miss
much of the message coming
from another person.
 Health care workers must put
their own issues aside and
focus 100% on their patients.
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APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 8 – Overcoming Personal and Psychological
Communication Barriers
 A health care worker who has
these poor attitudes while
communicating with patients is
likely to alienate them. The
result is that patients will attach
little value to what the health
care worker is saying.
 Health care workers must learn
to overcome or put aside
personal and psychological
barriers.
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APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 9 – Cultural Communication Barriers
 Culture includes values,
beliefs, and customs that
are common among a
group of people.
 Cultural communication
barriers include language,
health practices and beliefs,
eye contact, and religion.
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APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 9 – Language
 Language may be the most
obvious communication barrier.
 If the patient has some Englishspeaking ability, the health care
worker can speak slowly and
use simple words and gestures
or pictures.
 If the patient has no Englishspeaking ability, then the health
care worker should find an
interpreter, if possible.
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APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 9 – Health Beliefs
 Some cultures have beliefs about
health practices and treatments
that conflict with what the health
care worker prescribes.
 In these cases, the health care
worker must keep in mind that
the patient has the right to refuse
treatment.
 Health care workers should be
sensitive to these cultural
conflicts and work with patients to
make sure that they are getting
the required care and treatment.
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APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 9 – Eye Contact
 Differing cultural views on what
is or is not appropriate eye
contact can inhibit good
communication.
 In some cultures direct eye
contact is viewed as
disrespectful.
 Health care workers must
respect and adjust to the
patient’s cultural differences.
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APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 9 – Religion
 Religion is an organized belief
in a higher power.
 Religious beliefs can influence
many aspects of people’s lives
including birth, life, diet, illness,
and death.
 It is helpful for health care
workers to be aware of some
common religious influences so
that they can effectively treat
and interact with patients of
various backgrounds.
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APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 10 – Physical Communication Barriers
 Patients who are physically or
mentally impaired provide
challenges when trying to
communicate important health
information.
 Physical challenges that can effect
communication include:
▫ Problems with hearing, vision, and
speech
▫ Mental challenges
▫ Current physical and mental state
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APPLIED EDUCATIONAL SYSTEMS
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Lesson 10 – Hearing Challenges
 Deaf patients:
▫ Use sign language if possible.
▫ Utilize body language and
gestures.
▫ Face the patient when speaking.
 Hard-of-hearing patients:
▫ Face the patient when speaking.
▫ Speak clearly at a moderate pace.
▫ Keep sentences short and
uncomplicated.
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APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 10 – Vision Challenges
 Blind patients:
▫ Speak softly to them.
▫ Announce your presence.
▫ Describe procedures as they are
happening.
▫ Explain unusual noises.
 Low-vision patients:
▫ Volunteer to turn on more lights.
▫ Use bigger body gestures.
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APPLIED EDUCATIONAL SYSTEMS
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Lesson 10 – Speech Challenges
 Aphasia
▫ Speech problems that originate
with damage to the brain
▫ Patients may struggle both with
speaking and with writing
▫ Health care workers must be
patient and considerate by
speaking clearly and simply.
 Dysarthria
▫ Trouble with particular sounds
and slurring words
▫ Health care workers should be
patient and encourage these
patients to speak slowly and to
use hand gestures.
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APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 10 – Physically or Mentally Challenged
 When interacting with a patient in
a wheelchair, it is respectful for
the health care worker to also be
seated.
 Health care workers must also
be sensitive to patients who are
mentally or emotionally
challenged. They must be
prepared for anything and treat
these patients with calmness,
respect, and courtesy.
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APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 10 – Current Physical or Mental State
 Patients may not be able to
communicate clearly if they are:
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Very ill or in physical pain
On strong medication
Upset or confused
Experiencing a great deal of
stress
 Health care workers must
understand the context of the
situation when interacting with
patients. They must be alert to
situations that might interfere with
effective communication.
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APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 11 – Environmental Communication Barriers
 Environmental barriers
include:
▫ Noise and activity levels
▫ Physical arrangement
and comfort
▫ Time
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APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 11 – Noise and Activity Levels
 A noisy or active environment
makes it difficult for both the
patient and health care worker
to follow a conversation. It can
also make patients anxious.
 Health care workers should
strive to control the noise and
activity levels in common areas
where patient-health care
worker conversations might
take place.
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APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 11 – Physical Arrangement and Comfort
 In some health care facilities,
patients may have to
communicate with clerical
workers through glass. These
may make some patients feel
unwanted or isolated.
 If the setting is either too hot or
too cold, patients and health care
workers may be uncomfortable
and distracted.
 Health care workers should try to
make the physical arrangement
as welcoming and comfortable as
possible for themselves and for
patients.
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APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 11 – Time
 Time can be a communication
barrier if not enough of it is
devoted to interacting with a
patient.
 A hurried conversation or
exam can result in lost or
overlooked patient information.
It can also leave the patient
feeling unimportant and
distrustful.
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APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 12 – Quiz
In this lesson, you will take a quiz on
communication barriers.
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APPLIED EDUCATIONAL SYSTEMS
Health Science
Patients
 13. Interaction
 14. Education
 15. Quiz
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Go
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APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 13 – Patient Interaction
 Feeling confident, comfortable,
and competent during patient
interaction takes practice and
experience.
 Patient interaction involves
several stages:
▫ Preparation
▫ Introduction
▫ Assessment
▫ Treating and monitoring
▫ Feedback and follow-up
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APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 13 – Preparation
 Health care workers should
take a moment to prepare
before entering a hospital
room or an exam room.
 Review the patient’s chart:
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Patient’s name
Health history
Chief complaint
Special needs or
precautions
APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 13 – Introduction
 Health care workers should enter
the room calmly and formally
introduce themselves to the
patient.
▫ Name
▫ Position
▫ Purpose for being there
 More important than the actual
words in the introduction is the
manner in which they are
delivered. Health care workers
should be positive and genuine.
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Lesson 13 – Assessment
 Assessment is when a health
care worker makes
observations and evaluates a
patient’s condition.
 Assessment includes the
patient’s:
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Appearance
Personality
Attitude
Reaction to the health care
worker
▫ Vital signs
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APPLIED EDUCATIONAL SYSTEMS
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Lesson 13 – Treating and Monitoring
 Treating a patient involves
reading and following a doctor’s
orders.
 Before treating a patient, the
health care worker should
describe the procedure in lay
terms and explain why it is being
done and what it should
accomplish.
 While treating a patient, health
care workers must constantly
monitor the patient, looking for
any signs of change, good or bad.
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APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 13 – Feedback and Follow-Up
 After completing treatment for
patients, health care workers
should assess the patients again.
▫ Ask patients how they are feeling.
▫ Take vital signs.
 Then health care workers should
give patients feedback about the
treatments.
▫ Let patients know how well they
performed.
▫ Give pointers or tips about getting
better results the next time.
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Health Science
Lesson 14 – Patient Education
 Health care workers often find
themselves in the role of
teacher. Patients are the
students.
 Patient education can occur in
one-on-one conversation or as
a presentation to a group.
 Patient education can also
occur in the written form, called
patient education literature.
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APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 14 – Patient Questions
 Patient questions often create
patient education situations.
 Health care workers should be
prepared to answer these types
of questions:
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How did I get it?
How long will it last?
Am I going to die?
Is it curable?
Will I need medication? Will I
need surgery?
▫ Will I be the same after I have
recovered?
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APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 14 – One-on-One Conversation
 In one-on-one situations,
health care workers must teach
patients about treatments,
procedures, therapy, and
equipment.
 Health care workers are
responsible for making sure
patients fully understand what
is expected of them.
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APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 14 – Group Presentation
 Health care workers may be required
to deliver presentations for patient
education purposes.
 To prepare, health care workers
should ask the following questions:
▫ Who is the audience?
▫ What is the audience’s interest in
the topic?
▫ Should the presentation be formal
or informal?
▫ Are supporting materials
necessary?
▫ What type of audiovisual will be
most effective?
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APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 15 – Quiz
In this lesson, you will take a quiz on patient
interaction.
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APPLIED EDUCATIONAL SYSTEMS
Health Science
Documentation
 16. Documentation
 17. Reporting
 18. Quiz
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Go
Go
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APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 16 – Types of Documentation
 There are many types of
documentation in health
care, and they vary from one
agency to another.
 Some standard
documentation includes:
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Health histories
Notes
Initial evaluations
Progress reports
Discharge reports
APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 16 – Health Histories
 The health history provides the
doctor with important information
about the patient.
 Health histories generally include:
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General Statistical Data
Chief Complaint
Present Illness
Review of Systems
Past History
Family History
Personal/Sociocultural History
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APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 16 – SOAP Notes
 SOAP is an acronym for:
▫
▫
▫
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Subjective
Objective
Assessment
Plan
 When an agency uses SOAP
notes, then all employees know
where to look for information and
in what format they will find it.
 These notes eliminate some
excess writing and reading for
health care workers.
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APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 16 – Narrative Notes
 The narrative note method tells
the patient’s story. These notes
occur in chronological order as
the events take place.
 The advantage to the narrative
method is that health care
workers can describe how a
patient’s status, treatment, etc.
has changed.
 The disadvantage to this method
is that it can be more timeconsuming than the SOAP
method.
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APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 16 – Initial Evaluation
 An initial evaluation is the
groundwork for a patient’s file.
 An initial evaluation includes:
▫ Patient identification
information
▫ Referral information: reason,
referral history, referral
diagnosis, requested
treatment, complicating factors
▫ Evaluation
▫ Diagnosis with rationale for
treatment
▫ Treatment plan: prescriptions,
follow-up appointments,
frequency and duration, goals
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APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 16 – Progress Report
 A progress report contains
information regarding a patient’s
on-going care, treatment, and
progress.
 Progress reports occur over a
specified length of time, which
can be days, weeks, months, etc.
 The purpose of a progress report
is to support and give evidence of
the need for the patient’s
continued medical care.
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APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 16 – Progress Report (continued)
 Progress reports should contain
the following information:
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Patient information
Current evaluation
Diagnosis
Treatment
Assessment
Complications
Recommendations, changes,
goals
APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 16 – Discharge Report
 A discharge report has two
functions:
▫ It releases the patient back to
their regular lifestyle,
sometimes with some
restrictions.
▫ It gives a record of the
interactivity among health care
providers, as it documents the
patient’s success from the
initial evaluation to release.
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APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 16 – Discharge Report (continued)
 Discharge reports should contain
the following information:
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Patient information
Final evaluation
Diagnosis
Treatment
Assessment
Complications
Recommendations and goals
APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 17 – Documentation Guidelines
 Use a black ink pen.
 Write information neatly and in
concise language.
 Sign any information inserted into
a patient file. Signature should
always include the author’s name
or initials, the position or title, and
the date and time.
 Correct errors appropriately. If
errors are made, the author should
draw a single line through the
error, write the word “error,” and
initial it. Errors should never be
erased or covered with correction
fluid.
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APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 17 – Documentation Guidelines (continued)
 Do not leave empty spaces
between lines of data.
 Record items in chronological
order.
 Only use abbreviations that are
approved by the agency.
 Do not record information
performed or observed by
another health care worker.
 When necessary, destroy
documents properly using a
paper shredder.
 Double-check for the correct
patient, chart, and form.
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APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 17 – Fact versus Opinion
 When documenting or
reporting patient information,
health care workers must be
careful to only include facts
and to conceal their own
opinions.
 To understand the difference
between fact and opinion, it is
helpful to distinguish between
subjective and objective
observations.
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APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 17 – Subjective and Objective Observations
 Subjective observations are
often called symptoms. They are
not seen or felt. Instead, they are
comments or complaints made
by the patient.
 Objective observations are
typically called signs. They can
be measured or seen.
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APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 17 – Making Objective Observations
 During patient interaction, health
care workers must constantly
make observations:
▫ Sight - Unusual skin color,
swelling, rashes, sores
▫ Smell - Body odor or unusual
odors from the breath, urine,
stools, or wounds
▫ Touch - Pulse and the condition
of the skin, including
temperature, swelling, and
dryness or perspiration
▫ Sound - Respirations, coughing,
and impaired or slurred speech
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APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 17 – Documenting Observations
 Both subjective and objective
observations have a place in
patient documentation.
 Objective observations should
make up most of the report.
 Subjective statements made by
the patient may also be
included. However, they should
be recorded in the patient’s
exact words and quotation
marks should surround them.
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APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 17 – Eliciting Information
 Health care workers must
know how to ask the right
questions in order to get the
information that they require.
 They should ask broad
questions that encourage
patients to reply with more
than “yes” or “no” answers.
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APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 17 – Confidentiality
 The information that goes into a
patient’s file is confidential.
 Health care workers must be
sensitive to that confidentiality:
▫ Ask patients for personal
information in a private
environment.
▫ Be careful to close file folders
before setting them down.
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APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 18 – Quiz
In this lesson, you will take a quiz on
documentation.
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APPLIED EDUCATIONAL SYSTEMS
Health Science
Communication Technology
 19. Telephone Skills
Go
 20. Other Technology
 21. Quiz
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Go
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APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 19 – Telephone Communication
 A telephone conversation
may be the first
communication patients
have with a health care
agency.
 This initial conversation can
create an impression that
patients may hold onto for
the rest of their connection
with the agency.
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APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 19 – Telephone Etiquette: Greeting
 Good telephone etiquette
includes a proper greeting.
 When health care workers
answer the phone, they
should identify themselves,
the agency, and possibly
their department right away.
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APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 19 – Telephone Etiquette: Voice
 Health care workers should
strive for a clear voice with a
normal volume.
 When appropriate, they
should vary tone, pitch, and
volume for emphasis.
 Health care workers should
hold the phone’s mouthpiece
about one inch from the
mouth.
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APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 19 – Telephone Etiquette: Courtesy
 Courtesy involves being polite,
gracious, helpful, and
considerate.
 While on the telephone, health
care workers should use the
other person’s name and say
“please” and “thank you.”
 They should be careful not to
interrupt the other person.
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APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 19 – Telephone Etiquette: Attention
 Depending on what field of
health care work they are
in, the atmosphere around
the telephone can be very
busy and noisy.
 Health care workers must
block out what is going on
around them and focus on
the caller.
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APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 19 – Taking Telephone Messages
 Phone messages should include:
▫ The full name of the caller with the
correct spelling
▫ The caller’s telephone number with
the area code and extension
number, if applicable
▫ The best time of day to return the
call
▫ A brief message about the nature or
purpose of the call
▫ The date and time the call was
received
▫ A brief note of any action that was
taken
▫ Their own initials in case there are
any questions about the message
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APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 19 – Test Results and Triage
 The telephone should not be used
to communicate bad news or
complex information.
 The telephone is often used for
triage. In these cases, a patient
and health care worker discuss
the patient’s condition over the
telephone and determine whether
the patient should be seen by a
physician immediately or whether
an appointment can be scheduled
for a later date.
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APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 19 – Answering Machines and Services
 An answering machine is used to
deliver a message to callers and
record calls from patients. The
message typically has instructions
for callers with emergencies.
 Answering services are more
efficient in that the caller will be
connected to an operator. The
operator is responsible for taking
calls and information, and then
contacting the health care worker
that is on duty to cover
emergencies.
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APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 20 – Electronic Communication
 Automatic routing telephone
systems (ARU)
 Paging systems
 Cellular phones
 Facsimile, or fax, machines
 Electronic mail.
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APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 20 – Automatic Routing Units
 With automatic routing unit
(ARU), many telephone calls can
be answered simultaneously.
 A recorded message provides a
series of directions. The
directions instruct the caller to
press a number on the telephone
key pad to reach a person or a
department.
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APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 20 – Paging Systems
 In many health care
agencies, workers carry
pagers. When the workers
are needed, their pagers
will beep and display either
a telephone number or a
digital text message.
 Pagers cannot be used for
two-way communication.
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APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 20 – Cellular Phones
 Unlike pagers, cellular phones
are two-way communication
tools.
 Cellular phone signals can be
picked up by scanners. So,
private patient information
should never be discussed
using cellular phones.
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APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 20 – Fax Machines
 Fax machines are used to quickly
transmit data over telephone lines.
 Confidentiality can be a problem
when using a fax machine. Health
care workers should:
▫ Get patient permission before
faxing records.
▫ Never fax financial information.
▫ Contact the receiver before and
after sending a fax.
▫ Attach a cover sheet that
contains a confidentiality
statement.
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APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 20 – Electronic Mail
 Communication among health care
workers, agencies, and insurance
companies all take place using email.
 E-mail often takes the place of
printed interoffice communication.
 E-mail should never be used to
communicate confidential patient
information because e-mails can
be intercepted.
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APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 21 – Quiz
In this lesson, you will take a quiz on
communication technology.
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APPLIED EDUCATIONAL SYSTEMS
Health Science
Reflect
 How can you apply active listening skills to your
everyday life and the lives of those around you?
 Compare and contrast subjective and objective
information in reporting.
 Your patient is very hard-of-hearing and speaking loudly
does not seem to be working. What should you do?
 Do you think that you have any personal barriers that
would prevent you from communicating effectively with
another person? If so, what can you do to overcome
your own personal communication barriers?
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APPLIED EDUCATIONAL SYSTEMS
Health Science
Reflect – Key Questions
 Why is effective communication important in the
health care industry?
 How do attitudes of respect and sensitivity affect
communication?
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