‘© Uses maxims as guides for what to consider in, situation © Has holistic understanding of the client, which Improves decision making © Focuses on long term goal Kt STAGE (Expert) © Performance is fluid, flexible, and highly proficient. © No longer requires rules, guidelines, or ‘maxims to connect an understanding of the situations to appropriate actions © Inclined to take a.certain action be ‘felt right”. Interchange of information between ‘people: exchange of Ideas and thoughts. in addition, thoughts are ‘conveyed to other not only buy spoken or written ‘words but also by gestures or body actions ‘© Verbal Communication uses spoken or written words : © Nonverbal communication uses gestures, facial expressions, posture/galt, body” movements, physical appearance, eye contact and tone of voice ‘¢ Components of communication a. Sender-is the person who encodes and deliver message 'b. Message- the content of the ‘communication, may contain verbal, nonverbal, and symbolic language - Receiver - the person who receives and decodes the message 4. Channel- means of conveying and receiving messages through visual, auditory and tactile senses ‘e. Response/feedback- message returned by the receiver to the sender ‘+ Pace and Intonation - modifies the feeling and the Impact of the message Clarity and Brevity ~ message that Is direct and simple ‘Timing and Relevance ~ require choice of time and consideration of client's interest and concern Adaptability ~ message needs to be altered in ‘accordance with behavioral cues from the client Credibility ~ means worthiness of belief, ‘trustworthiness, and reliability Humor — used to help clients adjust to difficult and painful situation Y Written or computer-based Served as a permanent record of client's Information and progress care Formal, legal document that provide evidence of aclient’s care PURPOSES OF DOCUMENTATION ‘Planning client care * Communication ‘For legal documents purposes + For research For education ‘* Reimbursement * For statistics, reporting, epidemiology * Auditing health agencies * Health care analysis, ‘TYPES OF RECORDS * Source-Orlented Medical Record (Traditional Client Record/ SOM) i > Each person or department makes notations in a’separate section/s of client’s chart > Specific information is easier to locate * Components of SOMR Admission sheet Face sheet Medical history and physical examination and sheet iagnostic finding sheet TPR graphic sheet Doctor's treatment and order sheet ‘Therapeutic sheet Special flow sheet Medication record Nurses notes Client discharge plan and referral summary Initial nursing assessment vvy vv¥VVVVVVY PROBLEM-ORIENTED MEDICAL RECORD ‘Data about the cllent are recorded and arrange according to the sources ofthe Information ‘* Records integrates all data about the problem, gathered by members of health team ‘#4 BASIC COMPONENTS OF POMR 1. Database- contains all information from the patient ‘when he first entered the agency. It includes ‘nursing assessment, physician's history, social and family data, results of physician’s examination. 2, Problem lists- contains all the aspects of the Person's fe requiring health care -Keptin front of the chart Problems are listed in the order, which they are identified See una Ager ae ee en | Scanned with CamScannercontinually updated as new problems are identified and others are resolved 3. Initial list of orders or plan of care- made with reference to the active problems and are generated by the person who lists the problem 4, Progress notes- which includes nurses narrative notes (SOAPIE, SOAPIE, SOAPIER) . KARDEX « Provides a concise method of organizing and Tecording data about the client, making information readily ‘accessible to all members of the health care team «May be written in a pencil to ease in recording frequent change in detalls of cient care « Reeries toflip cards usually kept In portable file GENERAL GUIDELINES FOR RECORDING ‘© Date ond Time (0. Forlegal reasons and client's safety (+ Record the time in conventional manner (ex. 9:00 am or 3:15 pm) or according to 24-hour clock (military time) to avoid confusion about whether time was am or pm. & Timing ‘0 Adjust the frequency @ per client’s condition indicates ‘© Norecording should be done BEFORE providing nursing care : © Documenting should be done as soon _as possible after assessment/ Intervention © Legibllity ‘© Allentries must be easy to read prevent interpretation errors 4 Permanence (© Records are made in the dark permanent ink 4 Use of accepted terminology (© Use only commonly accepted abbreviation, symbols and terms that are specified by the agency © Correct Spelling (© Isessential for accuracy In recording ‘©. Hfunsure how to spell, look It up in @ dictionary or other resource book % Signature (© Each recording in nursing notes is signed by the nurse making It (© Include name and title (ex. Ralf Jake M. Faustino RN) © Accuracy © Gents name should be written on ‘each page of the clinical record + ‘Sequence ‘> Document events in the order which they occur ° lateness OPES Record only information that pertains to the client’s health problems and care ‘0 Recording irrelevant information may bbe considered an invasion of the client privacy % Completeness ‘© Information needs to be complete and helpful to the’client and health care professionals (© Care that is omitted because of llent’s refusal of treatment must also be recorded, Document what and why itis omitted and who was notified © Conciseness (© Recording needs to be brief as well as completed to save time In ; communication . Legal Prudence i (© Accurate and complete documentation should be a legal protection to the cllent and health care team © Confidentiality ‘0 Accurate notations consist of facts/ observations rather than opinions or Interpretation 7 eg. Fact “Client refused Medication” ¥ Opinion “Client was uncooperative” : 9 When recording MISTAKE is made, draw a line through it and write the words “mistaken entry” (avotd writing the word error) above or next to the original entry with your initials or name © Donot erase, blot out or use correction fluid © Write every line but not between line ‘© Ifa blank appears in the notation, draw a through the blank space and sign the notation ‘0 Only the health professionals who participate In the care of the client are allowed to read the chart lh Scanned with CamScannerTakes place when two or more people share | information about client care, either face-face o via nursit telephone = Focus i is-dire ‘Types of Reporting disea: Change-of-shifts report or endorsement = Decisi © For continuity of. care of clients by providing nursir quick summary of health care needs and = Interp details of care to be given - f * It is not merely reciting the content or the : KARDEX * : : J Telephone Reports : = Unive: © Provide clear, accurate and concise information: health v Date and time F Y group \ v__ Name of the person’giving the = Nurses information skills te i ¥ Subject of information received v Name and signature of the receiver ‘* Person receiving the information should repeat v Assess i It back to the sender to ensure accuracy v Diagn i ae Y Planni Telephone Orders v Implei Only RN’s may receive telephone orders, v Evaluz + Another RN should listen in another s telephone line to countercheck the detalls. ASSESSMENT ' | ., © Write the date and time the telephone order Assessment is was received. organization, * Write the complete order and read it back. about ‘* Question primary care provider about any _ the client hea order that is.unusual or contraindicated to © Pur, client’s condition se Activities dur * The order should be countersigned by the *° Data Collec Physician who made the order within the G Gathering ir Prescribed Period of Physical, psyc! , time (within'24 hours) Spiritual facto Transfer Report ~ lent Suppor “* Done when transferring a client to other unit, 7 Scanned with CamScannerpata collection methods - «Observing - gathers data by using the senses 2 aspects: = Noticing the data = Selecting, organizing and interpreting data « Interviewing — is a planned communication ora { j conversation with a purpose 2approaches: Directive % "7 Highly structured and elicits specific information Vv Uses closed-ended questions (YES/NO) y The nurse stablishes the purposes & control ‘the interview a YV_ Used when you need to elicit specific data ¥ ‘Used in emergency situation 7 Non-drective (rapport-bullding) = "7 Nurse allow the client to control the purpose, e subject matter & pacing non \ 4 ¥ Uses more open-ended questions v Advantage: allows the patient to explain certain information Stages of Interview The Opening ¥ Most important ¥ Establish rapport Y Orientation ‘ «The Body- the client communicates what he orshe > thinks, feels, and perceives in response to the ‘gy question © The Closing- termination of the interview Data Organization © Clustering/ organizing of facts into group of Information « Nurse uses a written/computerized data ‘systematically Validating Data * Double checking or verifying ig data to conf fis accurate and factual ~ 4 anapaiaa ‘Documenting Data + Accurate documentation is essential and should includ pote all data collected about the client’s health a 4 Types of array Assessment Scanned with CamScanner