WRITTEN
COMMUNICATION
Key Components to effective written
communication
Non-judgmental
Non-emotional
Correct grammar
Correct spelling
Principles of written
Write communication:
as near as possible to the time you’ve
delivered the care
Write simply and clearly
Write
legibly (if hand-written) and as error-free
as possible if keyed into a computer
Insert
dates and times as accurately as
possible when specific events and
circumstances occurred
Avoid giving personal opinions
Avoidwriting anything judgemental -Report
factually what you have observed.
Written communication IN
HEALTHCARE
Forms of written communication:
Paper charting
Interdepartmental memos
E-mail
Electronic Health Care Records (EHR’s)
Text messages
Patient education information
Discharge instructions
Misinterpretation in
communication
Words can mean different things to different
people
Healthcareworkers use acronyms and medical
terminology that lay people, including patients
and families, may not understand
CASE EXAMPLE
A new monitor technician in a local hospital ICU is
being oriented to the unit.
A new patient is admitted from surgery and she
overhears the nurses talking about the “cabbage
patient” (CABG – coronary artery bypass graft)
Patient records
) 4 main areas of error in patient records:
1. Making false entries
2. Not maintaining adequate records
3. Stating that certain care or observations
were carried out when they weren’t
4. Failure to implement an action plan when
a problem is discovered
E-mail guidelines
Include a specific subject line
Keep it focused
Identify yourself
Do not e-mail an angry message
Proofread before sending
Be courteous
Do not assume your e-mail is private
Avoid fancy fonts
Ct,,,
Ensure what you writer is not
interpreted as
o insulting or abusive
o prejudiced
o racist, sexist, ageist or discriminatory
in any way
REPORTS
Can be hourly, daily, weekly, monthly
Oral or written
Change of shift
Nurse to nurse
Promotes continuity
Report on client health status, care
required for next shift, significant facts,
head to toe assessment, pertinent labs,
priority needs, treatments, family issues
TYPES OF REPORTS
End of shift
Telephone orders reports
Legal reports
Incidents reports
Transfer reports
Census report
End of Shift Report
Keep professional
Avoid judgemental language
Include assistive personnel
Telephone Reports
Check link on telephone etiquette
[Link]
Inform physician of changes
Client transfers to different units
Result reports from lab or radiology
Client transfers to different institutions
Infoneeded: When call made, to whom,
info given
Keep clear, accurate, repeat info if
Telephone Orders
Physician to RN
Physician must co-sign within 24 hours
Nightime, emergency orders
Guidelines and procedure per
institution
Becareful, precise and accurate with
order
Write
order as said by physician,
repeat it back
Receiving & Documenting Telephone Orders
Write down the time, date and order given on the
physician’s order sheet
Read order back to physician to ensure it is
accurately recorded
Record the physician’s name on the physician’s
order sheet, state “telephone order”
Sign your name by the entry with your title
Always follow the agency’s policies
• Some agencies have abbreviation of TORB
(telephone order read back)
Transfer Reports
Unit to unit report
Phone or in person
All pertinent data about patient
Send all belongings with client
Review clothing/belonging list prior
to transfer
Transfer Sheet Documentation
Incident Reports
Any event not considered routine (falls,
needlesticks, med errors, accidental
omissions, visitor injury)
Risk Management will analyze trends
Changes in policy/procedure, educational
programs may be related to findings
Notify supervisor, physician of incident
Nurse who witnesses makes out report
Do not assign blame, be objective, facts
Tips for Documentation
Accurate, timely, thorough, factual, neat
Use only approved abbreviations & terms
Blue or black ink
Always get and give report
Focus on a team approach
Date, time each entry, do not block chart
Document in a timely fashion
Follow the nursing process
Use appropriate forms
RECORD KEEPING
There are many reasons for keeping
records in health care, but two stand out
above all others:
to
compile a complete record of the
patient’s/client’s journey through
services
to
enable continuity of care for the
patient/client both within and between
services
USES OF MEDICAL RECORDS
Permanent account
Sharing information
Quality Assurance
Accreditation
Reimbursement
Education
Research
Legal evidence
The records we keep in health care need
to be clear, accurate, honest and timely
They should be written as near as
possible to the actual time of occurrence
of the events they describe).
Different means of record-keeping are used
in health care settings.
Hand-written records
Computer-based systems
Figure 36-8 An example of narrative notes.
Two Types of Client Records
Source-Orientated Records
• Traditional record (organized according to the source of
documented information)
• Each person/department makes notations in separate section (s)
using narrative charting
• Disadvantage: fragmented documentation
Problem-Orientated Records
• Data arranged according to client’s health problems
• Arranged information of importance: goal directed care, promote
recording pertinent information & to facilitate communication
with health professionals
• Four components: data base, problem list, plan of care, &
progress notes
Components of Source-Oriented
Record
Admission sheet Initial
nursing
Graphic record assessment
MAR Daily care record
Nurses Special flow sheet
notes
Progress Medical H&P
notes
Diagnostic Consultation
reports
records
Physician’s order
Discharge plan
sheet
Referral summary
Problem-Oriented Record
Problem-oriented medical record (POMR)
Arranged according to client problems
Advantages
Encourages collaboration
Problem list alerts caregivers to client’s needs
Disadvantages
Caregivers differ in ability to use format
Vigilance to maintain up-to-date problem list
Inefficient
POMR Components
Database
Problem list
Derived from database
Listed in order identified
Updated
Plan of care
Progress notes
Same sheet for all notes
POMR Progress Notes
SOAPIER format frequently used
Subjective
Objective
Assessment
Plan
Interventions
Evaluation
Revision
Other Forms of Written Communication
Nursing Care Plan –
• List of Client’s problems, goals, nursing interventions, evaluations
• Promotes-prevention, reduction or resolution of problems
• Legal document-permanent record-each entry is signed
Nursing Kardex - Quick reference- Current information about client and care
• Information changes frequently
• Not a permanent record -
Checklists-Form of documentation-initials or a check mark used when care is
similar each day
Flow Sheets -recording for frequently repeated assessment data
• Graphic record (vital signs) & Fluid Balance Sheet (I & O)
Other Sheets:
• Medication Administration Record
• Skin & Safety/Fall Assessments
• Admissions, Transfer, Referral, Discharge
• Other facility and or state and federal required documentation
Note….
Know how to use the information systems and tools in
your workplace
Protect,and do not share with anyone, any passwords or
‘Smartcards’ given to you to enable you to access
systems
Make sure written records are not left in public places
where unauthorised people might see them, and that
any electronic system is protected before you sign out.
Principles of RECORD KEEPING
Accurate
Honesty
Non-judgemental/offensive
No breach of confidentiality
Handwritelegibly and key-in competently to
computer systems
Sign all your entries
Make sure your entries are dated and timed as
close to the actual time of the events as possible
Record events accurately and clearly
CT..
Focus on facts, not speculation
Avoid unnecessary abbreviations – ‘DNA’
means ‘deoxyribonucleic acid’ in some
places, but ‘Did Not Attendin others – avoid
abbreviations if you can!
Do not change or alter anything someone
else has written, or change anything you
have written previously; if you do need to
amend something you have written, cross
Do’s and Don’ts
Do Don’t
Chart changes Leave blank spaces
Show follow-up Chart in advance
Read prior notes Use vague terms
Be timely Chart for others
Objective, factual Use “patient” or
Correct errors “client”
Chart teaching Alter record
Quotes Record assumptions
Responses
Conclusion
Questions?
Comments?