# Communication

Communication: The exchange of information in a clear manner.

• Based on behavior, conscious and unconscious.

• Verbal and nonverbal

Internal Factors: Specific to examiner and promote good communication

1. Liking others

2. Expressing empathy

3. Ability to listen

4. Self-Awareness

External Factors: Relates to physical setting

• Ensure privacy

• Prevent interruptions

• Create a conducive environment

• Equal status setting

• Appropriate attire

• Documenting responses

10 Traps of Communication

• Providing false assurance or reassurance

• Giving unwanted advice

• Using authority

• Using avoidance language

• Engaging in distancing

• Using professional jargon

• Using leading or biased questions

• Talking too much

• Interrupting

• Using "why" questions

Nonverbal Communication: Establishes rapport and conveys info while giving clues to understanding

• Physical appearance

• Posture

• Gestures

• Facial expression

• Eye contact

• Voice

• And touch

Health Literacy

• Ability to use numeric info, understand and remember instruction.

• Oral teaching, written materials, and teach back

The Interview

• Health Interview: Structured interaction between nurse and patient with mutual goal of optimal health.

• 3 Phases

1. Introduction

• Introduce yourself and your role

2. Working Phase

   • Gather data

     • Open-ended questions

       • Ask for narrative information

     • Close-ended questions

       • Direct questions that ask specific information

       • Yes/No

3. Closing

   • Signal the end→gives patient chance to share concerns

   • Summarize what you've learned

• Responses

  • Facilitation, silence, reflection, empathy, clarification → patients frame of reference

  • Confrontation, interpretation, explanation, summary →nurses frame of reference

The Complete Health History

1. Biographic data

• Name, address, phone #, age, D.O.B, gender, pronouns, relationship status, race, ethnic origin, 1st language, occupation

2. Chief Complaint

• Leads to diagnosis and treatment

• Not a diagnostic statement

3. History of chief complaint

• Identify:

  • Location

  • Characteristics

  • Quantity or Quality/Severity

  • Timing: Onset, Duration, Frequency

  • Setting

  • Aggravating or Relieving Factors

  • Associated Factors

  • Patient's Perception

4. Comprehensive History

• Medical

  • Past medications

  • Allergies and Reactions (includes drug, environmental, and food allergies)

  • Past blood transfusions and any reactions

  • Recent screenings/tests

  • Chronic medical conditions

  • Past diagnoses (childhood and adult)

  • Immunizations

  • Past surgical procedures

  • Serious injuries or functional limitations

  • Obstetric History

5. Medication Reconciliation

6. Family History

• Illnesses similar to the patient's illness

• History of major diseases

• Familial disease and cancer history. Note age at onset of illness and outcome

• Ethnic and racial background of the family

• Create a pedigree (genogram) diagram (notes disorders of past three generations in a family tree diagram)

7. Review of Systems

• Evaluate each system head to toe. Double check that no details are missing. Evaluate health promotion practices.

  • Subjective data section

• General Overall Health State

• Skin, Hair, and Nails

• Head

• Eyes

• Ears

• Nose and Sinuses

• Mouth and Throat

• Neck

• Breast

• Axilla

• Respiratory System

• Cardiovascular

• Peripheral Vascular

• Gastrointestinal

Documentation, EHR, Reporting

• Provides accurate data and information

• Decreases misinterpretation

• Consistency

• A standardized national model documenting patient care improves nursing care, research, and evidence-based nursing care.

• Begins at arrival, ends at discharge

• Nursing documentation

  • patient's health care needs and goals

  • aspects of nursing care

  • Interventions

  • patient responses

  • essential information for continuity of care

• Shannon's communication theory

  • messaging of data, information, knowledge, and wisdom provides the individual pieces of data that nurses collect from patients

  • Examples: temperature or blood pressure as data, which become information when they are put together to give us better knowledge about the patient

• Completeness and legibility

• Reasons for encounter, assessments, and diagnoses

• Documentation of the plan of care, the patient's progress, and any changes in diagnosis and treatment.

• Completion of documentation as soon as possible after care is given

  • Don't wait until end of shift

• Timeliness of documentation

• care plan, interventions, the patient's outcomes or response to care, and assessment of the patient's ability to manage after discharge

• Flowsheet

  • Reduce time and redundancy

  • Rows and Columns

    • Assessment, interventions, outcomes

    • Date and times

• Narrative

  • Text notation of patient care

  • Not-machine readable and disorganized

• Source Oriented

  • Not team-oriented or shared method.

  • Results in fragmented care.

• Problem Oriented

  • A problem approach to documentation based on assessment data.

Charting by Exception

• Records only abnormal or clinically significant data.

• Reduce charting time by assuming certain norms

• Facility defines "normal"

Case Management/Clinical Pathways

• Provides and documents high-quality, cost-effective delivery of patient care

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• Uses standard of care

• Goal to achieve realistic outcomes

• Incorporates use and documentation of standardized, evidence-based patient care that leads to achievement of outcomes.

• EHR= digital version of the patient's chart

• Provides real-time information about the patient's health

• Updated continuously to ensure right patient and info

• Contains medical history, treatment plans, diagnostic test results, current and previous health diagnoses, allergies, and medications

• 2 types of documentation

  • Objective: observable and measurable

    • what the health professional observes by inspecting, palpating, percussing, and auscultating during the physical examination

    • signs

  • Subjective: can be open to interpretation

    • what the patient says about himself or herself. The interview is the first and the best chance a person has to tell you what he or she perceives the health state to be.

    • symptoms

• Electronic list of medications given or not given

• Times for administration

• Paper→ Signature

• Bar-coded medication administration into the process of medication administration.

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• A portable scanner for wristband and meds and verification

• Alerts nurse to errors

• Reduces errors.

• (CPOE) feature of EHRs that allows providers to enter orders such as medications or treatment plans directly into the EHR system.

• Automatic notification to appropriate department and updates pt record

• Reduce rates or errors

• Provide health care providers with the right information at the right time for the right patient

• Provides real-time, accurate information to help providers make appropriate decisions.

• Point of Care

• Workflow Support

• Medication Support

• Modify communication techniques based on patient

• Consider developmental stage, age, parents, cultural or religious beliefs, LGBTQ, and differences in communication like limited English.