brush the teeth helps the client understand the message e. Unresponsive 1)When communicating with an unresponsive person use touch along with the spoken word and try to elicit a response from the client 2)Asking a closed question such as, "Can you hear me?" and observing for nonverbal cues that may indicate the client has received the message is one way to elicit a response
3)Speak to the client in a manner that assumes the client can hear every word that is spoken; avoid having conversations about the client's status or that are irrelevant to the client at the bedside f. Those not speaking English1.Seek an interpreter fluent in the client's primary language if the client does not speak English; until an interpreter is available, communication must take place through nonverbal means 2.Use pictures, environmental cues, and body language to communicate with a client who speaks a different language II. Documenting and Reporting A. Documentation 1.The act of making an entry in the record is referred to as documentation or charting 2.Communicating healthcare information is an important aspect of providing nursing care 3.The client record (medical record) provides a description of the nursing and medical care received by the client 4.The information should be written clearly, concisely, and accurately 5.The record is a written or computer-based legal documentation of the client's health status that includes the client's healthcare problems, treatment and responses B. Purpose of records 1. Communication tool for healthcare teama.The record serves as a means of communication between nursing personnel and other care providers to plan a client's health care b.Communication among healthcare professionals is essential in providing care to clients and prevents fragmentation, repetition, and delays in client care 2. Legal document a.The record is a legal document that provides verification of the quality of care that a client receives
b.All information in the client record is confidential and access to the record is restricted to only those health professionals involved in the client's care 3. Financial billing a. Documentation of health care received by the client is also a means for reimbursement for services provided b. Before the client's record can be released to insurance companies, the client must authorize in writing what portions of the record to release4. Educationa.Healthcare students may also use documentation for educational purposes by comparing actual cases to textbook cases b.Educators may use client records as a source for teaching students c.A review of the medical records may indicate a need for continuing education for the nursing staff or other healthcare providers d.It is important that records used for educational purposes protect clients' privacy at all times5. Assessment: health records help an agency identify services utilized by clients in order to plan staffing, educational, and fiscal needs6. Research: the record may also provide vital statistics and
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- Fall '17
- Adrian Hailey