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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.
Indication that the message was received from the receiver allows you to determine if the message was understood the it was intended.
Some cases you may have to repeat the info & even demonstrate what is needed from the receiver.
Exchange of messages or info without using words. Your posture, movements, gestures, & facial expression, gives the pt clear signals about you.
(1) Avoid interruption. (2) Passive & Active (2 types of listening). (3) Concentrate on the message being sent by the pt & its purpose.
Involves hearing what the speaker is saying, but not listening with enough effort to become personally, intensely involved in what is being said.
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.
Deals with all the needs of the pt, including physical, emotional, social economic, & spiritual needs.
You must use what you have learned about human relations & behavior to develop this with pt. Relationship.
(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.
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.
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.
(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.
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).
(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.
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.
Dividers of a different size & color than a file folder. Should always be used when a file is removed from file storage.
(Everyone (staff) needs to know what the colors mean). Consists of labels that indicate a number, a letter,or an alphanumerical character.
(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.
Factors for good communication
(1) Willing to understand the message. (2) Ability to understand the message. (3) Overcome cultural difference.
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