Download Communications

APPLIED EDUCATIONAL SYSTEMS
Communications
Health Science and Technology Education
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
Communications
 Explore Go
 Learn and Practice Go
 Reflect Go
 Reinforce Go
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
Explore
You will play a game that will
highlight the importance of
effective communication.
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
TABLE OF CONTENTS
Communications
Lessons
1–3
4–7
8 – 12
13 – 15
16 – 18
19 – 21
Table of Contents
Topic
Overview Go
Communication Go
Interpersonal Communication Go
Communication Barriers Go
Patients Go
Documentation Go
Communication Technology Go
APPLIED EDUCATIONAL SYSTEMS
Health Science
Overview
You will learn about:
 Communication process
 Communication barriers
 Types of documentation
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
Fedor Ivanov
Scenario:
 Brought father to hospital
 English is a second
language
 Hospital staff not
communicating effectively
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
Questions
1. What barriers prevented the hospital staff and Fedor
from communicating?
2. What could the hospital staff have done differently
to communicate effectively with Fedor?
3. What might happen if the hospital staff does not
improve the way they communicate with Fedor?
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
Key Question
1. Why is effective communication important in the
health care industry?
2. How do attitudes of respect and sensitivity affect
communication?
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
Communication
 1. Types of Communication Go
 2. Communication Process Go
 3. Quiz Go
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 1 – Communication in Health Care
 Process of exchanging
messages
–
–
–
–
–
health care workers
patients
patients’ families
students and visitors
administrators and business
contacts.
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 1 – Verbal Communication
 Use of language and words
 Most effective form
 Goals:
▫
▫
▫
▫
Establish rapport
Obtain information from patients
Confirm understanding
Relay information to other
health care workers
▫ Give instructions to patients
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 1 – Tone of Voice
 Expresses speaker’s feelings
 Patients can pick up on fear,
agitation, calmness, and
confidence
 Adjust tone of voice
appropriately to the situation
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 1 – Language Choice
 Translate medical terminology
into lay terms
 At the same time, health care
workers must avoid talking
down to patients by oversimplifying their language.
 They should also be careful to
enunciate words and avoid
mumbling.
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 1 – Written Communication
 Form of verbal communication
 Allows writer time to research
and to organize thoughts
 Must:
▫ Be accurate and clear
▫ Be brief with logical
organization
▫ Be free of grammar, spelling,
and punctuation errors
▫ Use appropriate vocabulary
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 1 – Selecting the Correct Form
 Would message be better delivered
orally?
 Does the message require a written
record?
 What format?
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 1 – Writing Memos
 Often used in the health
care industry
 Standard parts:
▫
▫
▫
▫
▫
TO:
FROM:
DATE:
SUBJECT:
body
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 1 – The Five W’s
1. Who is the audience?
2. What is the purpose of
the message?
3. Why is the message
important?
4. When did or will the event
occur?
5. Where did or will the
event take place?
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 1 – Nonverbal Communication
 Used in addition to or as a
substitute for language
 Includes:
▫ Eye contact and facial
expressions
▫ Gestures and body language
▫ Physical appearance
▫ Touch
▫ Proximity
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 1 – Eye Contact and Facial Expressions
 Direct eye contact sends a
powerful and positive message
 Smiles and other facial
expressions
 Be conscious of interpretation
and own expression
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 1 – Gestures and Body Language
 People use their bodies instead
of words
 Posture also conveys a
message.
 Read and use gestures and
body language
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 1 – Physical Appearance
 Uniforms send the message
that they belong to the health
care field
 Physical appearance is also
expressed by grooming
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 1 – Touch
 Touch can communicate
many things.
 Touch can also be
misinterpreted
 Be conscientious to touch
patients with only kindness
and respect.
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 1 – Proximity
 Physical space between people
 Includes:
▫ Distance between people
▫ Height
▫ Odor
 Sensitivity and professionalism
are required when patient
proximity is an issue
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 2 – Communication Process
 Communication is a process.
 The sender-receiver model is
a way to break down the
process into steps.
 Use with active listening
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 2 – Sender-Receiver Model
 The sender is the person
who encodes, or gives,
information.
 The receiver is the person
who decodes, or accepts, the
information.
 The message is the
information that is being
communicated.
 Other elements include
frame of reference and
feedback.
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 2 – Active Listening Skills










Show interest.
Be alert.
Maintain eye contact.
Avoid interrupting.
Pay attention.
Avoid thinking ahead for a
response.
Try to ignore personal
prejudices.
Ignore distractions by moving to
a quiet place.
Watch the speaker closely for
nonverbal contradictions.
Maintain a positive attitude.
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 2 – Restatement, Reflection, and Clarification
 Restatement involves repeating
the message back to the sender
in the receiver’s own words.
 Reflection involves responding
with empathy.
 Clarification occurs when the
receiver asks questions to get a
more concise explanation or to
clear up any confusion about
the message.
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 2 – Other Effective Communication Skills
 Be conscious of your own
body language, including
posture and eye contact.
 Avoid any display of
anger.
 Speak slowly, softly, and
clearly.
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 3 – Quiz
In this lesson, you will take a quiz on types of
communication and communication processes.
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
Interpersonal Communication
 4. General Guidelines
Go
 5. Group Communication
 6. Directions
 7. Quiz
Table of Contents
Go
Go
Go
APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 4 – Attitudes and Behaviors
 Adopt acceptable attitudes
and behaviors
–
–
–
–
Courtesy
Respect
Sensitivity to boundaries
Empathy
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 4 – Courtesy
 Involves being polite,
gracious, helpful, and
considerate
 Overcome personal and
other issues unrelated to the
job
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 4 – Respect
 Approach another person
with a feeling of esteem or
regard
 Theme in any study of
communication in health
care
 Without proper respect,
communication can quickly
veer towards failure.
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 4 – Sensitivity to Boundaries
 Sensitivity is ability to see
and appreciate the
personal traits of others
 Sensitivity to boundaries is
ability to recognize and
observe the emotional and
physical limits of others
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 4 – Empathy
 Ability to share in
someone else’s feelings
or emotions
 Patients who are lonely or
facing serious surgeries or
terminal illnesses are in
special need of empathy
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 4 – Diversity
 Put aside all personal and cultural
bias
 Treat all people fairly, equally, and
with sensitivity
 Be aware that others have cultural
and personal biases
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 4 – Diversity (continued)
 Diversity includes the following:
▫
▫
▫
▫
▫
▫
▫
▫
▫
Race
Gender
Age
Ethnicity
Socioeconomic status
Occupation
Health status
Religion
Sexual orientation
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 4 – Criticism
 Constructive criticism can
build people up and inspire
them to do better.
 Non-constructive criticism
serves only to tear people
down and discourage them.
 Be prepared to accept and
give constructive criticism
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 4 – Accepting Constructive Criticism
 When people receive
constructive criticism, they
should appreciate it.
 People who receive
criticism should avoid
making excuses, getting
angry, and blaming others.
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 4 – Giving Constructive Criticism
 When giving criticism, people
should put themselves in the
other’s place.
 Choose words carefully and
speak kindly and considerately
 Allow the other person a
moment to accept what is said
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 5 – Group Communication
 Health care workers must
effectively communicate with their
colleagues.
 Health care workers must put
aside all personal prejudice and
treat team members fairly and
equally and so that they can
communicate effectively in group
situations.
 Successful group situations also
involve an understanding of
communication patterns,
interaction, and participation.
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 5 – Communication Patterns
 Chain-of-communication
pattern
 Wheel-of-communication
pattern
 All-channel communication
pattern
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 5 – Group Interaction
 Conformity occurs when
individuals change their opinions
or beliefs to match that of the
group.
 In some instances, conformity
can be bad, as it may cause
people to go against their beliefs
and values.
 In the professional world,
conformity can be good. It is
good when people conform to
behave appropriately in the
professional atmosphere.
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 5 – Group Participation
 Understand the group goals and
own roles within the group
 In meeting situations, group
members must:
▫
▫
▫
▫
▫
▫
Be prepared.
Use active listening skills.
Focus on the discussion.
Share relevant ideas.
Respect others.
Follow through with
assignments.
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 6 – Directions
 In the health care field, it
is critical that directions
are carried out correctly.
 In order for this to occur,
directions must both be
given and taken
accurately.
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 6 – Giving Directions
 When giving directions:
▫ Keep instructions simple and
brief
▫ Give directions in a logical,
chronological order
▫ Adjust language and complexity
to the patient’s ability
▫ Have the patient restate
▫ Correct any misunderstanding
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 6 – Following Directions
 When following directions:
▫
▫
▫
▫
Table of Contents
Be diligent
Ask questions
Take notes
Follow through
APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 7 – Quiz
In this lesson, you will take a quiz on
interpersonal communication.
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
Communication Barriers
 8. Personal Barriers Go
 9. Cultural Barriers Go
 10. Physical Barriers Go
 11. Environmental Barriers Go
 12. Quiz Go
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 8 – Communication Barriers
 Many types of barriers
 A communication barrier:
– make it difficult to send a clear
message
– understand message being sent
– provide appropriate feedback.
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 8 – Personal Communication Barriers
 Can occur within either participant in
communication
 Can result from emotions and
attitudes, resistance to change,
preconceptions, and self-absorption
 Can form out of prejudice and
personality, including traits such as
closed-mindedness, judging, belief
in stereotypes, and preaching or
moralizing
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 8 – Emotions and Attitudes
 Extreme emotions interfere with
ability to concentrate
 Attitudes can create barriers.
These attitudes may include:
▫ Prejudice
▫ Selective comprehension
▫ Complacency
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 8 – Preconceptions
 Preconceptions are similar to
prejudice.
 Typically directed toward to a
single person, rather than a
group
 Create barriers when people
disregard what another is
saying simply because they
disagree or they do not care for
the other person
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 8 – Resistance to Change
 Health care workers may have
resistance themselves, or they
may have to deal with a patient’s
resistance.
 Be flexible and open-minded
 Communicate the benefits of
change in a positive way to
patients
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 8 – Self-Absorption
 When people are preoccupied,
they can miss much of the
message coming from another
person
 Put own issues aside and focus
100% on their patients
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 8 – Overcoming Personal and Psychological
Communication Barriers
 Poor attitudes alienate patients
 Patients will attach little value to
what is said
 Learn to overcome or put aside
personal and psychological
barriers
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 9 – Cultural Communication Barriers
 Values, beliefs, and
customs that are common
among a group of people
 Barriers include:
–
–
–
–
language
health practices and beliefs
eye contact
religion
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 9 – Language
 Most obvious communication
barrier
 Speak slowly and use simple
words and gestures or pictures.
 Find an interpreter, if possible.
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 9 – Health Beliefs
 Beliefs about health practices
and treatments may conflict
 Patient has the right to refuse
treatment
 Be sensitive to these cultural
conflicts
 Work with patients to make sure
that they are getting the required
care and treatment
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 9 – Eye Contact
 Differing cultural views on what
is or is not appropriate eye
contact can inhibit good
communication.
 In some cultures direct eye
contact is viewed as
disrespectful.
 Respect and adjust to the
patient’s cultural differences
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 9 – Religion
 Organized belief in a higher
power
 Influence many aspects of
people’s lives including birth,
life, diet, illness, and death
 Be aware of common religious
influences
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 10 – Physical Communication Barriers
 Patients who are physically or
mentally impaired provide
challenges when trying to
communicate important health
information.
 Physical challenges that can
effect communication include:
▫ Problems with hearing, vision, and
speech
▫ Mental challenges
▫ Current physical and mental state
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 10 – Hearing Challenges
 Deaf patients:
▫ Use sign language if possible.
▫ Utilize body language and
gestures.
▫ Face the patient when speaking.
 Hard-of-hearing patients:
▫ Face the patient when speaking.
▫ Speak clearly at a moderate pace.
▫ Keep sentences short and
uncomplicated.
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 10 – Vision Challenges
 Blind patients:
▫ Speak softly to them.
▫ Announce your presence.
▫ Describe procedures as they are
happening.
▫ Explain unusual noises.
 Low-vision patients:
▫ Volunteer to turn on more lights.
▫ Use bigger body gestures.
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 10 – Speech Challenges
 Aphasia
▫ Speech problems that originate
with damage to the brain
▫ Patients may struggle both with
speaking and with writing
▫ Health care workers must be
patient and considerate by
speaking clearly and simply.
 Dysarthria
▫ Trouble with particular sounds
and slurring words
▫ Health care workers should be
patient and encourage these
patients to speak slowly and to
use hand gestures.
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 10 – Physically or Mentally Challenged
 When interacting with a patient in
a wheelchair, it is respectful for
the health care worker to also be
seated.
 Health care workers must also
be sensitive to patients who are
mentally or emotionally
challenged. They must be
prepared for anything and treat
these patients with calmness,
respect, and courtesy.
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 10 – Current Physical or Mental State
 Patients may not be able to
communicate clearly if they are:
▫
▫
▫
▫
Very ill or in physical pain
On strong medication
Upset or confused
Experiencing a great deal of
stress
 Understand the context of the
situation when interacting with
patients.
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 11 – Environmental Communication Barriers
 Environmental barriers
include:
▫ Noise and activity levels
▫ Physical arrangement
and comfort
▫ Time
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 11 – Noise and Activity Levels
 Control the noise and activity
levels in common areas where
patient-health care worker
conversations might take place
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 11 – Physical Arrangement and Comfort
 Partitions and dividers
 Room temperature
 Make the physical arrangement
welcoming and comfortable
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 11 – Time
 Communication barrier if not
enough of it is devoted to
interacting with a patient
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 12 – Quiz
In this lesson, you will take a quiz on
communication barriers.
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
Patients
 13. Interaction
 14. Education
 15. Quiz
Table of Contents
Go
Go
Go
APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 13 – Patient Interaction
 Feeling confident, comfortable,
and competent during patient
interaction takes practice and
experience.
 Patient interaction involves
several stages:
▫ Preparation
▫ Introduction
▫ Assessment
▫ Treating and monitoring
▫ Feedback and follow-up
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 13 – Preparation
 Take a moment to prepare
 Review the patient’s chart:
▫
▫
▫
▫
Table of Contents
Patient’s name
Health history
Chief complaint
Special needs or
precautions
APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 13 – Introduction
 Enter the room calmly and
formally introduce yourself.
▫ Name
▫ Position
▫ Purpose for being there
 Be positive and genuine
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 13 – Assessment
 Make observations and
evaluate a patient’s condition
 Assessment includes the
patient’s:
▫
▫
▫
▫
Appearance
Personality
Attitude
Reaction to the health care
worker
▫ Vital signs
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 13 – Treating and Monitoring
 Treating a patient involves
reading and following a doctor’s
orders.
 Describe the procedure in lay
terms
 Monitor the patient, looking for
any signs of change, good or bad
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 13 – Feedback and Follow-Up
 Assess the patient again.
▫ Ask patients how they are feeling.
▫ Take vital signs.
 Give patients feedback about the
treatments.
▫ Let patients know how well they
performed.
▫ Give pointers or tips about getting
better results the next time.
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 14 – Patient Education
 One-on-one conversation or as
a presentation to a group
 Patient education literature
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 14 – Patient Questions
 Patient questions often create
patient education situations.
 Be prepared to answer these
questions:
▫
▫
▫
▫
▫
How did I get it?
How long will it last?
Am I going to die?
Is it curable?
Will I need medication? Will I
need surgery?
▫ Will I be the same after I have
recovered?
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 14 – One-on-One Conversation
 In one-on-one situations,
health care workers must teach
patients about treatments,
procedures, therapy, and
equipment.
 Make sure patients fully
understand what is expected of
them
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 14 – Group Presentation
 Health care workers may be required
to deliver presentations for patient
education purposes.
 To prepare, health care workers
should ask the following questions:
▫ Who is the audience?
▫ What is the audience’s interest in
the topic?
▫ Should the presentation be formal
or informal?
▫ Are supporting materials
necessary?
▫ What type of audiovisual will be
most effective?
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 15 – Quiz
In this lesson, you will take a quiz on patient
interaction.
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
Documentation
 16. Documentation
 17. Reporting
 18. Quiz
Table of Contents
Go
Go
Go
APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 16 – Types of Documentation
 Many types of
documentation and they vary
from one agency to another
 Some standard
documentation includes:
▫
▫
▫
▫
▫
Table of Contents
Health histories
Notes
Initial evaluations
Progress reports
Discharge reports
APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 16 – Health Histories
 Provides the doctor with important
information about the patient
 Health histories generally include:
▫
▫
▫
▫
▫
▫
▫
General Statistical Data
Chief Complaint
Present Illness
Review of Systems
Past History
Family History
Personal/Sociocultural History
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 16 – SOAP Notes
 SOAP is an acronym for:
▫
▫
▫
▫
Subjective
Objective
Assessment
Plan
 All employees know where to
look for information and in what
format they will find it
 Eliminate some excess writing
and reading for health care
workers
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 16 – Narrative Notes
 Tells the patient’s story
 Chronological order
 Can describe how a patient’s
status, treatment, etc. has
changed
 More time-consuming than the
SOAP method.
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 16 – Initial Evaluation
 Groundwork for a patient’s file
 An initial evaluation includes:
▫ Patient identification
information
▫ Referral information: reason,
referral history, referral
diagnosis, requested
treatment, complicating factors
▫ Evaluation
▫ Diagnosis with rationale for
treatment
▫ Treatment plan: prescriptions,
follow-up appointments,
frequency and duration, goals
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 16 – Progress Report
 Contains information regarding a
patient’s on-going care,
treatment, and progress
 Occur over a specified length of
time, which can be days, weeks,
months, etc.
 Support and give evidence of the
need for the patient’s continued
medical care
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 16 – Progress Report (continued)
 Progress reports should contain
the following information:
▫
▫
▫
▫
▫
▫
▫
Table of Contents
Patient information
Current evaluation
Diagnosis
Treatment
Assessment
Complications
Recommendations, changes,
goals
APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 16 – Discharge Report
 A discharge report has two
functions:
▫ It releases the patient back to
their regular lifestyle,
sometimes with some
restrictions.
▫ It gives a record of the
interactivity among health care
providers, as it documents the
patient’s success from the
initial evaluation to release.
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 16 – Discharge Report (continued)
 Discharge reports should contain
the following information:
▫
▫
▫
▫
▫
▫
▫
Table of Contents
Patient information
Final evaluation
Diagnosis
Treatment
Assessment
Complications
Recommendations and goals
APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 17 – Documentation Guidelines




Use a black ink pen.
Write neatly and concisely
Always include signature
Correct errors appropriately.
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 17 – Documentation Guidelines (continued)
 Do not leave empty spaces
 Record items in chronological
order.
 Only use abbreviations that are
approved by the agency.
 Do not record information
performed or observed by
another health care worker.
 Destroy documents properly
 Double-check for the correct
patient, chart, and form
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 17 – Fact versus Opinion
 Be careful to only include facts
and to conceal own opinions
 Subjective and objective
observations
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 17 – Subjective and Objective Observations
 Subjective observations are
often called symptoms. They are
not seen or felt. Instead, they are
comments or complaints made
by the patient.
 Objective observations are
typically called signs. They can
be measured or seen.
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 17 – Making Objective Observations
 Observe:
▫ Sight - Unusual skin color,
swelling, rashes, sores
▫ Smell - Body odor or unusual
odors from the breath, urine,
stools, or wounds
▫ Touch - Pulse and the
condition of the skin, including
temperature, swelling, and
dryness or perspiration
▫ Sound - Respirations,
coughing, and impaired or
slurred speech
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 17 – Documenting Observations
 Both subjective and objective
observations have a place in
patient documentation.
 Objective observations should
make up most of the report.
 Subjective statements made by
the patient may also be
included. However, they should
be recorded in the patient’s
exact words and quotation
marks should surround them.
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 17 – Eliciting Information
 Know how to ask the right
questions in order to get the
information
 Ask broad questions that
encourage patients to reply
with more than “yes” or “no”
answers.
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 17 – Confidentiality
 The information that goes into a
patient’s file is confidential.
 Be sensitive to confidentiality:
▫ Ask patients for personal
information in a private
environment.
▫ Be careful to close file folders
before setting them down.
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 18 – Quiz
In this lesson, you will take a quiz on
documentation.
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
Communication Technology
 19. Telephone Skills
Go
 20. Other Technology
 21. Quiz
Table of Contents
Go
Go
APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 19 – Telephone Communication
 May be the first
communication patients
have with a health care
agency
 Creates an impression
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 19 – Telephone Etiquette: Greeting
 Good telephone etiquette
includes a proper greeting.
 Identify yourself, the
agency, and possibly the
department
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 19 – Telephone Etiquette: Voice
 Use a clear voice with a
normal volume.
 Vary tone, pitch, and volume
for emphasis
 Hold the phone’s mouthpiece
about one inch from the
mouth
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 19 – Telephone Etiquette: Courtesy
 Be polite, gracious, helpful,
and considerate
 Use the other person’s name
and say “please” and “thank
you.”
 Be careful not to interrupt the
other person
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 19 – Telephone Etiquette: Attention
 Atmosphere around the
telephone can be very busy
and noisy
 Focus on the caller
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 19 – Taking Telephone Messages
 Phone messages should include:
▫ The full name of the caller with the
correct spelling
▫ The caller’s telephone number with
the area code and extension
number, if applicable
▫ The best time of day to return the
call
▫ A brief message about the nature or
purpose of the call
▫ The date and time the call was
received
▫ A brief note of any action that was
taken
▫ Their own initials in case there are
any questions about the message
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 19 – Test Results and Triage
 The telephone should not be used
to communicate bad news or
complex information.
 The telephone is often used for
triage.
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 19 – Answering Machines and Services
 Used to deliver a message to
callers and record calls from
patients.
 Answering services are more
efficient in that the caller will be
connected to an operator.
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 20 – Electronic Communication
 Automatic routing telephone
systems (ARU)
 Paging systems
 Cellular phones
 Facsimile, or fax, machines
 Electronic mail.
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 20 – Automatic Routing Units
 Many telephone calls can be
answered simultaneously
 Directions instruct the caller to
press a number on the telephone
key pad to reach a person or a
department.
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 20 – Paging Systems
 Pagers beep and display
either a telephone number
or a digital text message.
 Pagers cannot be used for
two-way communication.
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 20 – Cellular Phones
 Two-way communication tools
 Private patient information
should never be discussed
using cellular phones
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 20 – Fax Machines
 Used to quickly transmit data
over telephone lines
 When using a fax machine:
▫ Get patient permission before
faxing records.
▫ Never fax financial
information.
▫ Contact the receiver before
and after sending a fax.
▫ Attach a cover sheet that
contains a confidentiality
statement.
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 20 – Electronic Mail
 Communication among health care
workers, agencies, and insurance
companies
 Often takes the place of printed
interoffice communication
 Should never be used to
communicate confidential patient
information because e-mails can
be intercepted
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
Lesson 21 – Quiz
In this lesson, you will take a quiz on
communication technology.
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
Reflect
 Unit Questions
Go
 Key Questions
Go
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
Reflect – Unit Questions
1. How can you apply active listening skills to your
everyday life and the lives of those around you?
2. Compare and contrast subjective and objective
information in reporting.
3. Your patient is very hard-of-hearing and speaking loudly
does not seem to be working. What should you do?
4. Do you think that you have any personal barriers that
would prevent you from communicating effectively with
another person? If so, what can you do to overcome
your own personal communication barriers?
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
Reflect – Key Question
1. Why is effective communication important in the
health care industry?
2. How do attitudes of respect and sensitivity affect
communication?
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
Reinforce Project
Communication Skit
 You will write and perform skits that demonstrate
good and poor communication skills.
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
Reinforce Project
Culture and Religion
 You will research and present information on a culture
or religion, specifically its views on health care.
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
Reinforce Project
Medical Records
 You will practice several filing techniques, including
alphabetical, numerical, and categorical.
Table of Contents
APPLIED EDUCATIONAL SYSTEMS
Health Science
Reinforce Project
Telephone Etiquette
 You will take a telephone message during a role-play
exercise.
Table of Contents