Mod A ch. 9, 10, & 11 Test

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Mod A ch. 9, 10, & 11 Test

Communication

Clear exchange of info between a sender (person sending info) and a receiver (the person receiving info).

Way a message is delivered

Just as important as the message itself. (1) Be aware of the rate of your speech. (2) Ensure that your message is clear & concise. Avoid a monotone voice. (3) Match your tone to the message you're sending.

Feedback

Indication that the message was received from the receiver allows you to determine if the message was understood the it was intended.

Seek clarification

Some cases you may have to repeat the info & even demonstrate what is needed from the receiver.

Nonverbal communication

Exchange of messages or info without using words. Your posture, movements, gestures, & facial expression, gives the pt clear signals about you.

If you allow distracters to interfere with your listening

You will not obtain the info you need.

Good listener

(1) Avoid interruption. (2) Passive & Active (2 types of listening). (3) Concentrate on the message being sent by the pt & its purpose.

2 types of listening

(1) Passive (2) Active

Passive listening

Involves hearing what the speaker is saying, but not listening with enough effort to become personally, intensely involved in what is being said.

Active listening

Requires you to demonstrate listening by maintaining eye contact & providing responses (feedback) to indicate that you are listening & really thinking about what is being said.

Analyze a message

(1) Listener must be able to understand the message. (2) Listener must be willing to understand the message.

Council

A group that advises.

Counsel

To advise.

Stationary

Not movable.

Stationery

Paper used to write letters.

Holistic

Deals with all the needs of the pt, including physical, emotional, social economic, & spiritual needs.

Rapport

You must use what you have learned about human relations & behavior to develop this with pt. Relationship.

Improve communication

(1) Communicate in simple, everyday language. (2) Match your approach to the pt lv of readiness & ability to learn. (3) Identify any barriers to communication that may be evident, such as a history of noncompliance, a language barrier, reading ability, or physical or emotional state.

Handling pt complaints

(Good relationship, met guidelines of Medicare & prevents lawsuits) Cooperation of all members of the health care team. Working together reduces the risk of a complaint not being handled promptly & can help relieve pt anxiety & hostility.

Litigation

Lawsuit.

Requirements of handling pt complaints

(1) Take all complaints seriously. (2) Use tactful (nonoffensive) language when responding to a complaint, & reassure the pt that the complaint will be investigated. (3) Always alert the physician or office manager.

Medical office you will work with pt

Impaired vision, impaired hearing, diminished mental capacity, & other physical disabilities.

As people age they experience

Decline in vision & hearing. Changes occur in the senses of smell, taste, & touch.

Communicating with elderly pt

Speak clearly & slowly, using short sentences with slight pauses. Don't give lengthy explanations.

Maturation

Developmentally delayed pt are those who lag behind in this. They should not be confused with mentally impaired pt.

Communicate effectively with developmentally delayed pt

MA needs to address their level of maturation, not their chronological age.

Pt culture, beliefs, background, age, intelligence, & abilities

All need to be analyzed to establish a communication process that best fits the pt communication & learning style.

Medical records provide

Pt assessments, interventions, & communications. Confidential, legal documents used to record the health care services provided to an individual at a medical facility. (Serves as a legal document & planning care that pt receive)

When each document is added to the pt record

Latest info is always placed on top in chronological order because it indicates the pt current status.

Ownership

Physician owns the medical record, but the pt owns the info.

Source-oriented format

(Organized by type of service provided) Organize a medical record, the record has dividers to separate the medical info. Each divider has a color tab with the heading of the section on it. Document is added is placed on top.

Typical dividers

Include (1) History & physical exam (2) Progress notes (3) Medications

Problem-oriented medical record (POMR)

Arranged according to the pt health complaint. Each complaint is seen as a problem or condition that needs further action (e.g., tx, pt education).

SOAP

(1) Subjective data - info provided by the pt. (2) Objective data- obtained through the physical exam & the ROS, or the info that is observed. (3) Assessment- final diagnosis based on the info found from the CC & the physical exam. (4) Plan- plan of action or the tx action to be taken.

Charting

Process of documenting events in written form. It's an important part of the pt care because it communicates the pt condition & the care received. Because the pt record is a legal document, it's the medical practice's best defense against lawsuits & provides documentation for third-party payers.

Out guides

Dividers of a different size & color than a file folder. Should always be used when a file is removed from file storage.

Color-coding system

(Everyone (staff) needs to know what the colors mean). Consists of labels that indicate a number, a letter,or an alphanumerical character.

Alphabetical filing

(Broke down to units (1) Last name is key unit, or 1st unit (2) First name or initial is the 2nd unit (3) Middle name or initial is the 3rd unit.) Most common method of filing.

Tickler file

Needs to be organized & checked frequently.

Close ended questions

Yes or no answers.

Open ended questions

Pt explain what they fully mean. Not a yes or no answer.

Good communication requires

Actively sending & receiving messages.

Verbal communication

Tone of speech.

Factors for good communication

(1) Willing to understand the message. (2) Ability to understand the message. (3) Overcome cultural difference.

Compliance

Asking in a polite way. Such as please.

Pt with limited understanding

Explain slowly & as they go along.

Pt care

Intelligence, beliefs, & disabilities.

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