Effective Communication in Healthcare

Effective Communication

HCS/325

Introduction

In a long-term care (LTC) nursing facility, the primary types of communication are documentation and verbal. The physicians and all of the nursing staff have to document every aspect of each patient’s care. Effective documentation provides a legal record of care and how the patient responds to the type of care which they received. By documenting, the physicians and nurses are giving written communication to those who provide follow up care. When the nursing staff begins their shift, the nurse gives a report of their previous shift’s activities. For example; the night nurse gives the day nurse reports on each patient. Without these verbal reports the nurses, Certified Nursing Assistants (CNAs) would need to read each individual patient’s chart to see what happened on the previous shift, this would take away valuable time from the patient and could lead to negative patient care.

By using documentation this type of communication provides a legal record of care for each patient. The LTC facility uses several documents to monitor each resident’s care and the outcomes from the care. Each resident also has a personal medical record (PMR) these record contain the resident’s medical, family, social history, assessments, dietary needs, treatment plans, orders, prescriptions, progress notes, and lab results. With this chart the LTC has a complete and accurate look into each individual resident and their medical history and progression of care.

Included in their record the, Medication Administration Record (MAR) this is used to document the time, dose, how and when it was administered by the nurse. This record also provides communication in regards to new physician orders, which would include changes for a new medication or discontinuation of a medication. The nurse that distributes the medications must chart immediately when the medication is given and the result.

Also in the documentation is the patient’s treatment...