Chapter 24 Communication Mosby items and derived items
![Chapter 24 Communication Mosby items and derived items © 2005 by Mosby, Inc. Chapter 24 Communication Mosby items and derived items © 2005 by Mosby, Inc.](https://slidetodoc.com/presentation_image/70c7a811bbf5c5bff7db0dc91c8f5e52/image-1.jpg)
Chapter 24 Communication Mosby items and derived items © 2005 by Mosby, Inc.
![Communication and Interpersonal Relationships Vehicle for establishing a therapeutic relationship n Means of influencing Communication and Interpersonal Relationships Vehicle for establishing a therapeutic relationship n Means of influencing](http://slidetodoc.com/presentation_image/70c7a811bbf5c5bff7db0dc91c8f5e52/image-2.jpg)
Communication and Interpersonal Relationships Vehicle for establishing a therapeutic relationship n Means of influencing the behavior of another to lead to successful outcomes n Mosby items and derived items © 2005 by Mosby, Inc.
![Levels of Communication Intrapersonal n Interpersonal n Transpersonal n Small group n Public n Levels of Communication Intrapersonal n Interpersonal n Transpersonal n Small group n Public n](http://slidetodoc.com/presentation_image/70c7a811bbf5c5bff7db0dc91c8f5e52/image-3.jpg)
Levels of Communication Intrapersonal n Interpersonal n Transpersonal n Small group n Public n Mosby items and derived items © 2005 by Mosby, Inc.
![Basic Elements of Communication Referent n Sender and receiver n Messages n Channels n Basic Elements of Communication Referent n Sender and receiver n Messages n Channels n](http://slidetodoc.com/presentation_image/70c7a811bbf5c5bff7db0dc91c8f5e52/image-4.jpg)
Basic Elements of Communication Referent n Sender and receiver n Messages n Channels n Feedback n Interpersonal variables n Environment n Mosby items and derived items © 2005 by Mosby, Inc.
![Forms of Communication Verbal n Nonverbal n Symbolic n Metacommunication n Mosby items and Forms of Communication Verbal n Nonverbal n Symbolic n Metacommunication n Mosby items and](http://slidetodoc.com/presentation_image/70c7a811bbf5c5bff7db0dc91c8f5e52/image-5.jpg)
Forms of Communication Verbal n Nonverbal n Symbolic n Metacommunication n Mosby items and derived items © 2005 by Mosby, Inc.
![Verbal Communication Vocabulary n Denotative and connotative meaning n Pacing n Intonation n Clarity Verbal Communication Vocabulary n Denotative and connotative meaning n Pacing n Intonation n Clarity](http://slidetodoc.com/presentation_image/70c7a811bbf5c5bff7db0dc91c8f5e52/image-6.jpg)
Verbal Communication Vocabulary n Denotative and connotative meaning n Pacing n Intonation n Clarity and brevity n Timing and relevance n Mosby items and derived items © 2005 by Mosby, Inc.
![Nonverbal Communication Personal appearance n Posture and gait n Facial expression n Eye contact Nonverbal Communication Personal appearance n Posture and gait n Facial expression n Eye contact](http://slidetodoc.com/presentation_image/70c7a811bbf5c5bff7db0dc91c8f5e52/image-7.jpg)
Nonverbal Communication Personal appearance n Posture and gait n Facial expression n Eye contact n Gestures n Sounds n Territoriality and personal space n Mosby items and derived items © 2005 by Mosby, Inc.
![Zones of Personal Space Intimate zone: 0 to 18 inches n Personal zone: 18 Zones of Personal Space Intimate zone: 0 to 18 inches n Personal zone: 18](http://slidetodoc.com/presentation_image/70c7a811bbf5c5bff7db0dc91c8f5e52/image-8.jpg)
Zones of Personal Space Intimate zone: 0 to 18 inches n Personal zone: 18 inches to 4 feet n Social zone: 4 to 12 feet n Public zone: 12 feet and beyond n Mosby items and derived items © 2005 by Mosby, Inc.
![Professional Helping Relationships Nurse—client n Nurse—family n Nurse—health team n Nurse—community n Mosby items Professional Helping Relationships Nurse—client n Nurse—family n Nurse—health team n Nurse—community n Mosby items](http://slidetodoc.com/presentation_image/70c7a811bbf5c5bff7db0dc91c8f5e52/image-9.jpg)
Professional Helping Relationships Nurse—client n Nurse—family n Nurse—health team n Nurse—community n Mosby items and derived items © 2005 by Mosby, Inc.
![Elements of Professional Communication Courtesy n Use of names n Privacy and confidentiality n Elements of Professional Communication Courtesy n Use of names n Privacy and confidentiality n](http://slidetodoc.com/presentation_image/70c7a811bbf5c5bff7db0dc91c8f5e52/image-10.jpg)
Elements of Professional Communication Courtesy n Use of names n Privacy and confidentiality n Trustworthiness n Autonomy and responsibility n Assertiveness n Mosby items and derived items © 2005 by Mosby, Inc.
![Communication in the Nursing Process n Assessment Physical and emotional factors l Developmental factors Communication in the Nursing Process n Assessment Physical and emotional factors l Developmental factors](http://slidetodoc.com/presentation_image/70c7a811bbf5c5bff7db0dc91c8f5e52/image-11.jpg)
Communication in the Nursing Process n Assessment Physical and emotional factors l Developmental factors l Sociocultural factors l Gender l Mosby items and derived items © 2005 by Mosby, Inc.
![Communication in the Nursing Process (cont’d) n Nursing diagnosis examples Impaired verbal communication l Communication in the Nursing Process (cont’d) n Nursing diagnosis examples Impaired verbal communication l](http://slidetodoc.com/presentation_image/70c7a811bbf5c5bff7db0dc91c8f5e52/image-12.jpg)
Communication in the Nursing Process (cont’d) n Nursing diagnosis examples Impaired verbal communication l Anxiety l Social isolation l Ineffective coping l Impaired social interaction l Powerlessness l Mosby items and derived items © 2005 by Mosby, Inc.
![Communication in the Nursing Process (cont’d) n Planning Goals and outcomes l Priorities l Communication in the Nursing Process (cont’d) n Planning Goals and outcomes l Priorities l](http://slidetodoc.com/presentation_image/70c7a811bbf5c5bff7db0dc91c8f5e52/image-13.jpg)
Communication in the Nursing Process (cont’d) n Planning Goals and outcomes l Priorities l Continuity of care l Mosby items and derived items © 2005 by Mosby, Inc.
![Communication in the Nursing Process (cont’d) n Implementation l Therapeutic communication techniques Mosby items Communication in the Nursing Process (cont’d) n Implementation l Therapeutic communication techniques Mosby items](http://slidetodoc.com/presentation_image/70c7a811bbf5c5bff7db0dc91c8f5e52/image-14.jpg)
Communication in the Nursing Process (cont’d) n Implementation l Therapeutic communication techniques Mosby items and derived items © 2005 by Mosby, Inc.
![Therapeutic Communication Techniques Active listening (SOLER) n Sharing observations n Sharing empathy n Sharing Therapeutic Communication Techniques Active listening (SOLER) n Sharing observations n Sharing empathy n Sharing](http://slidetodoc.com/presentation_image/70c7a811bbf5c5bff7db0dc91c8f5e52/image-15.jpg)
Therapeutic Communication Techniques Active listening (SOLER) n Sharing observations n Sharing empathy n Sharing hope n Sharing humor n Sharing feelings n Mosby items and derived items © 2005 by Mosby, Inc.
![Therapeutic Communication Techniques (cont’d) Using touch n Using silence n Providing information n Clarifying Therapeutic Communication Techniques (cont’d) Using touch n Using silence n Providing information n Clarifying](http://slidetodoc.com/presentation_image/70c7a811bbf5c5bff7db0dc91c8f5e52/image-16.jpg)
Therapeutic Communication Techniques (cont’d) Using touch n Using silence n Providing information n Clarifying n Focusing n Paraphrasing n Mosby items and derived items © 2005 by Mosby, Inc.
![Therapeutic Communication Techniques (cont’d) Asking relevant questions n Summarizing n Self-disclosure n Confrontation n Therapeutic Communication Techniques (cont’d) Asking relevant questions n Summarizing n Self-disclosure n Confrontation n](http://slidetodoc.com/presentation_image/70c7a811bbf5c5bff7db0dc91c8f5e52/image-17.jpg)
Therapeutic Communication Techniques (cont’d) Asking relevant questions n Summarizing n Self-disclosure n Confrontation n Mosby items and derived items © 2005 by Mosby, Inc.
![Nontherapeutic Communication Techniques Asking personal questions n Giving personal opinions n Changing the subject Nontherapeutic Communication Techniques Asking personal questions n Giving personal opinions n Changing the subject](http://slidetodoc.com/presentation_image/70c7a811bbf5c5bff7db0dc91c8f5e52/image-18.jpg)
Nontherapeutic Communication Techniques Asking personal questions n Giving personal opinions n Changing the subject n Automatic responses n False reassurance n Sympathy n Mosby items and derived items © 2005 by Mosby, Inc.
![Nontherapeutic Communication Techniques (cont’d) Asking for explanations n Approval or disapproval n Defensive responses Nontherapeutic Communication Techniques (cont’d) Asking for explanations n Approval or disapproval n Defensive responses](http://slidetodoc.com/presentation_image/70c7a811bbf5c5bff7db0dc91c8f5e52/image-19.jpg)
Nontherapeutic Communication Techniques (cont’d) Asking for explanations n Approval or disapproval n Defensive responses n Passive or aggressive responses n Arguing n Mosby items and derived items © 2005 by Mosby, Inc.
![Communication in the Nursing Process n Implementation l Adapting communication techniques for clients with Communication in the Nursing Process n Implementation l Adapting communication techniques for clients with](http://slidetodoc.com/presentation_image/70c7a811bbf5c5bff7db0dc91c8f5e52/image-20.jpg)
Communication in the Nursing Process n Implementation l Adapting communication techniques for clients with special needs Mosby items and derived items © 2005 by Mosby, Inc.
![Communication in the Nursing Process (cont’d) n Evaluation Analysis of communication patterns l Process Communication in the Nursing Process (cont’d) n Evaluation Analysis of communication patterns l Process](http://slidetodoc.com/presentation_image/70c7a811bbf5c5bff7db0dc91c8f5e52/image-21.jpg)
Communication in the Nursing Process (cont’d) n Evaluation Analysis of communication patterns l Process recordings l Mosby items and derived items © 2005 by Mosby, Inc.
![Chapter 25 Client Education Mosby items and derived items © 2005 by Mosby, Inc. Chapter 25 Client Education Mosby items and derived items © 2005 by Mosby, Inc.](http://slidetodoc.com/presentation_image/70c7a811bbf5c5bff7db0dc91c8f5e52/image-22.jpg)
Chapter 25 Client Education Mosby items and derived items © 2005 by Mosby, Inc.
![Standards n Joint Commission on Accreditation of Healthcare Organizations (JCAHO) Mosby items and derived Standards n Joint Commission on Accreditation of Healthcare Organizations (JCAHO) Mosby items and derived](http://slidetodoc.com/presentation_image/70c7a811bbf5c5bff7db0dc91c8f5e52/image-23.jpg)
Standards n Joint Commission on Accreditation of Healthcare Organizations (JCAHO) Mosby items and derived items © 2005 by Mosby, Inc.
![Purposes Maintenance and promotion of health and illness prevention n Restoration of health n Purposes Maintenance and promotion of health and illness prevention n Restoration of health n](http://slidetodoc.com/presentation_image/70c7a811bbf5c5bff7db0dc91c8f5e52/image-24.jpg)
Purposes Maintenance and promotion of health and illness prevention n Restoration of health n Coping with impaired functioning n Mosby items and derived items © 2005 by Mosby, Inc.
![Teaching Interactive process n Conscious, deliberate set of actions n Assist individuals to gain Teaching Interactive process n Conscious, deliberate set of actions n Assist individuals to gain](http://slidetodoc.com/presentation_image/70c7a811bbf5c5bff7db0dc91c8f5e52/image-25.jpg)
Teaching Interactive process n Conscious, deliberate set of actions n Assist individuals to gain knowledge, change attitudes, adopt new behaviors, perform skills n Mosby items and derived items © 2005 by Mosby, Inc.
![Learning n Acquisition of new knowledge, attitudes, behaviors, and skills Mosby items and derived Learning n Acquisition of new knowledge, attitudes, behaviors, and skills Mosby items and derived](http://slidetodoc.com/presentation_image/70c7a811bbf5c5bff7db0dc91c8f5e52/image-26.jpg)
Learning n Acquisition of new knowledge, attitudes, behaviors, and skills Mosby items and derived items © 2005 by Mosby, Inc.
![Role of the Nurse Ethical responsibility n Response to client requests n Identification of Role of the Nurse Ethical responsibility n Response to client requests n Identification of](http://slidetodoc.com/presentation_image/70c7a811bbf5c5bff7db0dc91c8f5e52/image-27.jpg)
Role of the Nurse Ethical responsibility n Response to client requests n Identification of client needs n Mosby items and derived items © 2005 by Mosby, Inc.
![Teaching as Communication Referent n Sender n Message n Channels n Receiver n Feedback Teaching as Communication Referent n Sender n Message n Channels n Receiver n Feedback](http://slidetodoc.com/presentation_image/70c7a811bbf5c5bff7db0dc91c8f5e52/image-28.jpg)
Teaching as Communication Referent n Sender n Message n Channels n Receiver n Feedback n Intrapersonal variables n Mosby items and derived items © 2005 by Mosby, Inc.
![Domains of Learning n Cognitive learning Knowledge l Comprehension l Application l Analysis l Domains of Learning n Cognitive learning Knowledge l Comprehension l Application l Analysis l](http://slidetodoc.com/presentation_image/70c7a811bbf5c5bff7db0dc91c8f5e52/image-29.jpg)
Domains of Learning n Cognitive learning Knowledge l Comprehension l Application l Analysis l Synthesis l Evaluation l Mosby items and derived items © 2005 by Mosby, Inc.
![Domains of Learning (cont'd) n Affective learning Receiving l Responding l Valuing l Organizing Domains of Learning (cont'd) n Affective learning Receiving l Responding l Valuing l Organizing](http://slidetodoc.com/presentation_image/70c7a811bbf5c5bff7db0dc91c8f5e52/image-30.jpg)
Domains of Learning (cont'd) n Affective learning Receiving l Responding l Valuing l Organizing l Characterizing l Mosby items and derived items © 2005 by Mosby, Inc.
![Domains of Learning (cont'd) n Psychomotor learning Perception l Set l Guided response l Domains of Learning (cont'd) n Psychomotor learning Perception l Set l Guided response l](http://slidetodoc.com/presentation_image/70c7a811bbf5c5bff7db0dc91c8f5e52/image-31.jpg)
Domains of Learning (cont'd) n Psychomotor learning Perception l Set l Guided response l Mechanism l Complex overt response l Adaptation l Origination l Mosby items and derived items © 2005 by Mosby, Inc.
![Basic Learning Principles Motivation to learn n Ability to learn n Developmental l Physical Basic Learning Principles Motivation to learn n Ability to learn n Developmental l Physical](http://slidetodoc.com/presentation_image/70c7a811bbf5c5bff7db0dc91c8f5e52/image-32.jpg)
Basic Learning Principles Motivation to learn n Ability to learn n Developmental l Physical l n Learning environment Mosby items and derived items © 2005 by Mosby, Inc.
![Teaching Process and Assessment Expectations of learning n Learning needs n Motivation to learn Teaching Process and Assessment Expectations of learning n Learning needs n Motivation to learn](http://slidetodoc.com/presentation_image/70c7a811bbf5c5bff7db0dc91c8f5e52/image-33.jpg)
Teaching Process and Assessment Expectations of learning n Learning needs n Motivation to learn n Ability to learn n Teaching environment n Resources for learning n Mosby items and derived items © 2005 by Mosby, Inc.
![Teaching Process and Nursing Diagnosis n Examples Deficient knowledge l Ineffective health maintenance l Teaching Process and Nursing Diagnosis n Examples Deficient knowledge l Ineffective health maintenance l](http://slidetodoc.com/presentation_image/70c7a811bbf5c5bff7db0dc91c8f5e52/image-34.jpg)
Teaching Process and Nursing Diagnosis n Examples Deficient knowledge l Ineffective health maintenance l Impaired home maintenance l Ineffective therapeutic regimen management l Mosby items and derived items © 2005 by Mosby, Inc.
![Teaching Process and Planning Learning objectives n Setting priorities n Timing n Organizing teaching Teaching Process and Planning Learning objectives n Setting priorities n Timing n Organizing teaching](http://slidetodoc.com/presentation_image/70c7a811bbf5c5bff7db0dc91c8f5e52/image-35.jpg)
Teaching Process and Planning Learning objectives n Setting priorities n Timing n Organizing teaching material n Maintaining attention and participation n Building on existing knowledge n Mosby items and derived items © 2005 by Mosby, Inc.
![Teaching Process and Planning Selection of teaching methods n Availability of teaching resources n Teaching Process and Planning Selection of teaching methods n Availability of teaching resources n](http://slidetodoc.com/presentation_image/70c7a811bbf5c5bff7db0dc91c8f5e52/image-36.jpg)
Teaching Process and Planning Selection of teaching methods n Availability of teaching resources n Writing teaching plans n Mosby items and derived items © 2005 by Mosby, Inc.
![Teaching Tools Printed material n Programmed instruction n Computer instruction n Non-print materials n Teaching Tools Printed material n Programmed instruction n Computer instruction n Non-print materials n](http://slidetodoc.com/presentation_image/70c7a811bbf5c5bff7db0dc91c8f5e52/image-37.jpg)
Teaching Tools Printed material n Programmed instruction n Computer instruction n Non-print materials n l Diagrams, charts, pictures, objects, audiovisuals Mosby items and derived items © 2005 by Mosby, Inc.
![Teaching Process and Implementation n Teaching approaches Telling l Selling l Participating l Entrusting Teaching Process and Implementation n Teaching approaches Telling l Selling l Participating l Entrusting](http://slidetodoc.com/presentation_image/70c7a811bbf5c5bff7db0dc91c8f5e52/image-38.jpg)
Teaching Process and Implementation n Teaching approaches Telling l Selling l Participating l Entrusting l Reinforcing l Mosby items and derived items © 2005 by Mosby, Inc.
![Teaching Process and Implementation (cont’d) Incorporating teaching with nursing care n Instructional methods n Teaching Process and Implementation (cont’d) Incorporating teaching with nursing care n Instructional methods n](http://slidetodoc.com/presentation_image/70c7a811bbf5c5bff7db0dc91c8f5e52/image-39.jpg)
Teaching Process and Implementation (cont’d) Incorporating teaching with nursing care n Instructional methods n One-on-one discussion l Group instruction l Preparatory instruction l Demonstrations l Mosby items and derived items © 2005 by Mosby, Inc.
![Teaching Process and Implementation (cont’d) n Instructional methods Analogies l Role playing l Simulation Teaching Process and Implementation (cont’d) n Instructional methods Analogies l Role playing l Simulation](http://slidetodoc.com/presentation_image/70c7a811bbf5c5bff7db0dc91c8f5e52/image-40.jpg)
Teaching Process and Implementation (cont’d) n Instructional methods Analogies l Role playing l Simulation l Mosby items and derived items © 2005 by Mosby, Inc.
![Teaching Process and Implementation (cont’d) n Particular client needs Illiteracy and disabilities l Cultural Teaching Process and Implementation (cont’d) n Particular client needs Illiteracy and disabilities l Cultural](http://slidetodoc.com/presentation_image/70c7a811bbf5c5bff7db0dc91c8f5e52/image-41.jpg)
Teaching Process and Implementation (cont’d) n Particular client needs Illiteracy and disabilities l Cultural background and language l Developmental stage l Mosby items and derived items © 2005 by Mosby, Inc.
![Teaching Process and Evaluation Measurement methods n Client expectations n Documentation n Mosby items Teaching Process and Evaluation Measurement methods n Client expectations n Documentation n Mosby items](http://slidetodoc.com/presentation_image/70c7a811bbf5c5bff7db0dc91c8f5e52/image-42.jpg)
Teaching Process and Evaluation Measurement methods n Client expectations n Documentation n Mosby items and derived items © 2005 by Mosby, Inc.
![Chapter 26 Documentation and Informatics Mosby items and derived items © 2005 by Mosby, Chapter 26 Documentation and Informatics Mosby items and derived items © 2005 by Mosby,](http://slidetodoc.com/presentation_image/70c7a811bbf5c5bff7db0dc91c8f5e52/image-43.jpg)
Chapter 26 Documentation and Informatics Mosby items and derived items © 2005 by Mosby, Inc.
![Confidentiality Nurses are legally and ethically obligated to keep client information confidential. n Nurses Confidentiality Nurses are legally and ethically obligated to keep client information confidential. n Nurses](http://slidetodoc.com/presentation_image/70c7a811bbf5c5bff7db0dc91c8f5e52/image-44.jpg)
Confidentiality Nurses are legally and ethically obligated to keep client information confidential. n Nurses are responsible for protecting records from all unauthorized readers. n HIPAA act requires disclosure or requests regarding health information. n Mosby items and derived items © 2005 by Mosby, Inc.
![Standards n The Joint Commission requires each client have an assessment: l n Physical, Standards n The Joint Commission requires each client have an assessment: l n Physical,](http://slidetodoc.com/presentation_image/70c7a811bbf5c5bff7db0dc91c8f5e52/image-45.jpg)
Standards n The Joint Commission requires each client have an assessment: l n Physical, psychosocial, environment, self-care, client education, and discharge planning needs Federal and state regulations, state statutes, standards of care, and accreditation agencies set nursing documentation standards. Mosby items and derived items © 2005 by Mosby, Inc.
![Multidisciplinary Communication Within the Health Care Team n Records or chart: l n Confidential Multidisciplinary Communication Within the Health Care Team n Records or chart: l n Confidential](http://slidetodoc.com/presentation_image/70c7a811bbf5c5bff7db0dc91c8f5e52/image-46.jpg)
Multidisciplinary Communication Within the Health Care Team n Records or chart: l n Confidential permanent legal document Reports: l Oral, written, audiotaped exchange of information Mosby items and derived items © 2005 by Mosby, Inc.
![Multidisciplinary Communication Within the Health Care Team n Consultations: l n A professional caregiver Multidisciplinary Communication Within the Health Care Team n Consultations: l n A professional caregiver](http://slidetodoc.com/presentation_image/70c7a811bbf5c5bff7db0dc91c8f5e52/image-47.jpg)
Multidisciplinary Communication Within the Health Care Team n Consultations: l n A professional caregiver providing formal advice to another caregiver Referrals: l Arrangement for services by another care provider Mosby items and derived items © 2005 by Mosby, Inc.
![Purposes of Records Communication Legal documentation Financial billing Education Research Auditing/monitori ng Mosby items Purposes of Records Communication Legal documentation Financial billing Education Research Auditing/monitori ng Mosby items](http://slidetodoc.com/presentation_image/70c7a811bbf5c5bff7db0dc91c8f5e52/image-48.jpg)
Purposes of Records Communication Legal documentation Financial billing Education Research Auditing/monitori ng Mosby items and derived items © 2005 by Mosby, Inc.
![Guidelines for Quality Documentation and Reporting Factual n Accurate n Complete n Current n Guidelines for Quality Documentation and Reporting Factual n Accurate n Complete n Current n](http://slidetodoc.com/presentation_image/70c7a811bbf5c5bff7db0dc91c8f5e52/image-49.jpg)
Guidelines for Quality Documentation and Reporting Factual n Accurate n Complete n Current n Organized n Mosby items and derived items © 2005 by Mosby, Inc.
![Methods of Recording n Narrative: l n The traditional method Problem-Oriented Medical Record (POMR): Methods of Recording n Narrative: l n The traditional method Problem-Oriented Medical Record (POMR):](http://slidetodoc.com/presentation_image/70c7a811bbf5c5bff7db0dc91c8f5e52/image-50.jpg)
Methods of Recording n Narrative: l n The traditional method Problem-Oriented Medical Record (POMR): Database l Problem list l Nursing care plan l Progress note l Mosby items and derived items © 2005 by Mosby, Inc.
![Methods of Recording: Progress Notes n SOAP: l n SOAPIE: l n Subjective, objective, Methods of Recording: Progress Notes n SOAP: l n SOAPIE: l n Subjective, objective,](http://slidetodoc.com/presentation_image/70c7a811bbf5c5bff7db0dc91c8f5e52/image-51.jpg)
Methods of Recording: Progress Notes n SOAP: l n SOAPIE: l n Subjective, objective, assessment, plan, intervention, evaluation PIE: l n Subjective, objective, assessment, plan Problem, intervention, evaluation Focus Charting (DAR): l Data, action, response Mosby items and derived items © 2005 by Mosby, Inc.
![Methods of Reporting n Source records: l n Charting by exception (CBE): l n Methods of Reporting n Source records: l n Charting by exception (CBE): l n](http://slidetodoc.com/presentation_image/70c7a811bbf5c5bff7db0dc91c8f5e52/image-52.jpg)
Methods of Reporting n Source records: l n Charting by exception (CBE): l n A separate section for each discipline Focuses on documenting deviations Case management plan and critical pathways: l Incorporates a multidisciplinary approach to care Mosby items and derived items © 2005 by Mosby, Inc.
![Common Record-Keeping Forms Admission nursing history form Flow sheets and graphic records Client care Common Record-Keeping Forms Admission nursing history form Flow sheets and graphic records Client care](http://slidetodoc.com/presentation_image/70c7a811bbf5c5bff7db0dc91c8f5e52/image-53.jpg)
Common Record-Keeping Forms Admission nursing history form Flow sheets and graphic records Client care summary or Kardex Acuity records Standardized care plans Discharge summary form Mosby items and derived items © 2005 by Mosby, Inc.
![Home Care Documentation Medicare has specific guidelines for establishing eligibility for home care. n Home Care Documentation Medicare has specific guidelines for establishing eligibility for home care. n](http://slidetodoc.com/presentation_image/70c7a811bbf5c5bff7db0dc91c8f5e52/image-54.jpg)
Home Care Documentation Medicare has specific guidelines for establishing eligibility for home care. n Documentation is the quality control and justification for reimbursement from Medicare, Medicaid, or private insurance. n Mosby items and derived items © 2005 by Mosby, Inc.
![Home Care Documentation n Nurses need to document all their services for payment. Mosby Home Care Documentation n Nurses need to document all their services for payment. Mosby](http://slidetodoc.com/presentation_image/70c7a811bbf5c5bff7db0dc91c8f5e52/image-55.jpg)
Home Care Documentation n Nurses need to document all their services for payment. Mosby items and derived items © 2005 by Mosby, Inc.
![Long-Term Health Care Documentation n n Governmental agencies are instrumental in determining the standards Long-Term Health Care Documentation n n Governmental agencies are instrumental in determining the standards](http://slidetodoc.com/presentation_image/70c7a811bbf5c5bff7db0dc91c8f5e52/image-56.jpg)
Long-Term Health Care Documentation n n Governmental agencies are instrumental in determining the standards and policies for documentation. The Omnibus Budget Reconciliation Act of 1987 includes Medicare and Medicaid legislation for long-term care documentation. Mosby items and derived items © 2005 by Mosby, Inc.
![Long-Term Health Care Documentation n The department of health in states governs the frequency Long-Term Health Care Documentation n The department of health in states governs the frequency](http://slidetodoc.com/presentation_image/70c7a811bbf5c5bff7db0dc91c8f5e52/image-57.jpg)
Long-Term Health Care Documentation n The department of health in states governs the frequency of written nursing records. Mosby items and derived items © 2005 by Mosby, Inc.
![Computerized Documentation Software programs allow nurses to enter assessment data. n Computers generate nursing Computerized Documentation Software programs allow nurses to enter assessment data. n Computers generate nursing](http://slidetodoc.com/presentation_image/70c7a811bbf5c5bff7db0dc91c8f5e52/image-58.jpg)
Computerized Documentation Software programs allow nurses to enter assessment data. n Computers generate nursing care plans and document care. n A complete computer-based patient care record (CPCR) is not without legal risks. n Mosby items and derived items © 2005 by Mosby, Inc.
![Reporting Change of shift n Telephone reports n Verbal or telephone orders n Transfer Reporting Change of shift n Telephone reports n Verbal or telephone orders n Transfer](http://slidetodoc.com/presentation_image/70c7a811bbf5c5bff7db0dc91c8f5e52/image-59.jpg)
Reporting Change of shift n Telephone reports n Verbal or telephone orders n Transfer reports n Incident reports n Mosby items and derived items © 2005 by Mosby, Inc.
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