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CHARTING DOCUMENTATION DATE TIME PLACE SIMPLE EXPLANATION TO WHOM WHO WAS PRESENT WHAT WAS DONE SIGNATURE INFORMED CONSENT Simple Consent Express consent Implied consent Inadequate Consent MALPRACTICE Depends on job description MEDICAL RECORDS Chart contains everything Entries must have date, time and signed with credentials Abbreviations must be approved by institution. GOOD SAMARITAN LAWS TO PROTECT PERSONS WHO GIVE MEDICAL AID IN EMERGENCY SITUATIONS. Cardiac Arrest Survival Act provides immunity for those who purchase Automatic External Defibrillators (AED). COMMUNICATION Effective communication skills allow you to establish and maintain good working relationships with patients, patients’ families and other health care professionals. FACTORS AFFECTING COMMUNICATION Perceptions Values Personal Space Emotions Sociocultural Background Knowledge Environment COMMUNICATION PROCESS SENDER RECEIVER COMMUNICATION PROCESS VERBAL NON-VERBAL: Stress; Contradict; Accent; Regulate; Substitute LEVELS OF COMMUNICATION Intrapersonal Interpersonal PERSONAL SPACE SOCIAL DISTANCE PERSONAL DISTANCE INTIMATE DISTANCE LISTENING SKILLS MOST COMMUNICATION TIME IS SPENT LISTENING! Good eye contact Watch for non-verbal signs Don’t cut patient off Be comfortable with silence COMMUNICATION #1 CAUSE FOR LAW SUITS!! CULTURAL DIFFERENCES Show respect Treat all equally Be aware of your own and patient’s nonverbal messages If you do not understand something, ask for clarification Humor Gender TIP In some cultures it is disrespectful to speak of the dead. Patient may be reluctant to provide detailed information on the family health history of dead relatives. Ask the patient if there has been any history of specific diseases in the family and not focus on the specific individual if that person is deceased. If unsuccessful, explain importance of this info, as it may provide clues to the patient’s condition. TIP Some Asian cultures calculate age from conception, not from the actual birth date. A newborn infant would be considered one year old. It is important to differentiate for pediatric patients because of the link between age and developmental milestones. SPECIAL COMMUNICATION SITUATIONS Sensory Alterations Sensory Deficit Sensory Deprivation Sensory Overload Altered Consciousness Chemical Influence Drug use Drug misuse Drug abuse Patient Assessment Data Collection Data Analysis Planning and Implementation Evaluation Data Collection Subjective: Anything the patient or person accompanying pt says that can affect the procedure Objective: What you see, hear, smell feel, or read in the patient’s chart Data Analysis Integrate Critical thinking by listing all subjective and objective date, then analyze. What data is relevant to the procedure? Planning and Implementation After analyzing the data you come up with a plan to take the x-ray and implement. Evaluation Were the patient’s needs met? Was the patient’s safety maintained? Was the patient’s skin intact? Did the pt complain of pain during exam? What problems occurred that I didn’t plan for? Any discomfort to patient? Did I use higher-level critical thinking to complete procedure? Activity John Gomez reports to the outpatient desk for a scheduled upright abdomen and UGI series. He states he feels ill and has had nausea and vomiting for 24 hours. His family is also ill. He is pale, sweating and dizzy when standing. He doesn’t think he will be able to swallow the barium What is the chief complaint? List objective and subjective data. What is your plan? Developing Harmonious Relationship Establishing guidelines Reducing Distance Listening Using silence Responding to underlying message Restating main idea Reflecting main idea Seeking and providing Clarification Making observations Exploring Validating Focusing REFER TO TEXT AMERICANS WITH DIABILITIES ACT 1990 Congress passed this to provide civil rights protection to persons with disabilities. Defines a disabled individual as “one who has a physical or mental impairment that substantially limits one or more major life activities” Provides equal employment opportunity GREIVING PROCESS Denial Anger Bargaining Depression Acceptance CASE STUDY Mr. Gomez is an elderly Mexican-American patient who has come to the radiology department for an abdominal radiograph. He has been diagnosed with colon cancer and has undergone a surgical procedure that resulted in a colostomy. He speaks very little English. His wife and daughter are with him. His wife is visibly upset and uncomfortable being in the hospital. How would you explain the procedure to Mr. Gomez? Would you involve his family? Mr Gomez us very uncomfortable lying flat on his back and says that he just wants to be left alone to die. How would you handle this situation? DEATH AND DYING Communication issues Be open to talk about anything dying pts want Discuss feelings about loss Listen!! Dying Patient’s Rights