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Dynamics of Care in Society
Written Communication &
Medical Documentation1
Written communication “practical writing”… for a specific purpose,
ex:ReportsBusiness lettersInteroffice memosManualsFormsApplicationsChart documentation
“Practical Writing” TypesNarrative writing…tells what happened,
paragraph form, Descriptive writing…details of person, object,
eventInformative writing…giving directions,
explaining how to, answering questions, making something easier to understand, use bullets or steps,
Persuasive writing..giving an opinion or stating a point of view and supporting it with reasons in order to persuade the reader to accept or possibly take action on it
Recording and ReportingRecord patient information completely & precisely
Record information only in secure & appropriate locations
Record any action you take concerning a patient (“if it is not documented…it didn’t happen”)
Just the facts…Minimize medical jargon (if for a patient)
Get started… get comfortable, be concise, have logical transitions of thought
Outline ideas… organize before you write * brainstorm* group similar ideas together* find unifying themes* have a beginning, middle, end
Revising…check for…* clarity* sentence & paragraph structure
Proofreading… refinement…check for…* grammar, punctuation, spelling* final touches
Drafting hints…
Tips for… “Well & Clearly Written”
- create an outline to clarify and order your concepts
- write a really bad first draft with no rewriting
- rewrite, read out loud, rewrite, read again and rewrite
- have colleagues comment on your draft
- trust feedback from reviewers and rewrite again
- let it sit, return for a fresh read out loud, and finalize
Ideas for Learning to Write Better
• Read examples you like and also review your colleague’s draft papers and edit them.
• Take course in essay writing - good analysis, clear arguments and exposition, and convincing conclusions.
• Write for broad audiences too - if you can capture them, you can capture professionals
• Read your writing out loud and then edit!
For Research Assistance…
UCLA Libraryunder services menu tab choose references & research help
Purposes of documentation in HC
1. Communication among the health care team
2. Assessment (vital signs, hx, symptoms…)
3. Quality Assurance (competence & quality of care)
4. Reimbursement (verification for insurances…)
5. Legal Record (admission of evidence)6. Education (use for training)7. Research: Useful Data Gained From
Patient Records
Examples:Nurse updates patient’s record with new info from patient
Doctor sees nurse’s note & orders cholesterol test
Pharmacist views medical history before filling prescription
Discharge planner evaluates physical therapist’s notes on progress in ambulation
(note the communication process w/in the medical record)
Ease of access to dataMultiple users simultaneouslyDifferent locationsVarious devices
Easy storage & retrieval; faster recording of data
Nearly unlimited file spaceEasy back-up for securityEasy to add or attach infoImproved legibility
Advantages of Computerized Documentation
Safe Computer Recordkeeping
1.Don’t share passwords/computer signature
2.Don’t leave logged-on terminal unattended
3.Follow protocol for correcting errors4.Allow only authorized personnel to
create, change, or delete files5.Back up records regularly6.Don’t leave patient info displayed on
monitor in view of others7.Keep running log of electronic copies
made of files8.Never use unencrypted email to send
protected health info9.Follow confidentiality procedures for
sensitive material
What you’ll find in the medical record…
Admission sheet – general demographic info, insurance info…
Graphic sheet – aka Flow sheet - for vital signs…
MD orders – for medications, instructions, procedures…
Progress notes – on patient’s progress, new or changing info from multiple health care team members
Medical history and exam –"Listen to your patient, he is telling you the diagnosis," Sir William Osler, M.D. – Johns Hopkins
Allergies, Immunizations, Childhood diseasesCurrent & past medicationsPrevious illnesses, Surgeries, Hospitalizations
Family medical historyReports – test results, lab results, consultations…
Psycho-Social History Marital status
OccupationEducationHobbiesDietAlcohol, drug & tobacco use/misuseSexual historyMiscellaneous – correspondence, AD, organ donor…
Good Medical Documentation Tips1.It is accurate (ex. Correct
spelling, Errors marked through, labeled with “error,” initialed, & dated…)
2.It is complete (ex. All supporting information – lab results …)
3.It is concise (ex. Only relevant information), just the facts
4.It is legible5.It is organized (ex. Most recent
information first, date stamped…)6. It is signed, initialed, dated
and/or timed *– as required
Progress Notes --- 3 Types
1. SOAP notesSubjective data
Statements from patient describing conditionSymptoms experienced
Objective dataData that provider can measure, see, feel, or smellTest results
Vital signs Assessment
Patient’s diagnosisPossible disorders to be ruled out
PlanDescription of what should be doneDiagnostic testsTreatmentsFollow-up
2. Charting by exception
• Covers only significant or abnormal findings
• Decreased charting time• Greater emphasis on significant data
• Easy retrieval of significant data• Timely bedside charting• Standardized assessment• Greater interdisciplinary communication
• Better tracking of important patient responses
• More cost effective
3. Narrative
Paragraph format Includes:
Contact with patientWhat was done for patientOutcomes
Can be time-consuming to write & difficult to read
It is the oldest & least structured type
Handout…
PROPER TELEPHONE COMMUNICATION
ANSWERING….
1.ANSWER PROMPTLY2.IDENTIFY SELF3.FIND OUT WHO IS CALLING 4.SPEAK COURTEOUSLY, CLEARLY &
PLEASANTLY5.USE DISCRETION IN RELEASING
INFORMATION, REMEMBER CONFIDENTIALITY
6.END CALL GRACEFULLY
Handout… SCREENING….
1.DON’T OFFEND CALLER2.ASK WHO IS CALLING, NATURE OF
BUSINESS OR EMERGENCY3.ANSWER QUESTIONS TACTFULLY4.ASK IF MESSAGE CAN BE LEFT5.PLACE ON HOLD AND GET GUIDANCE,
HELP IF NEEDED
TAKING A MESSAGE….
1.OBTAIN TIME, DATE, NAME OF CALLER , PURPOSE OF CALL
2.TAKE NOTES, REPEAT INFO BACK TO CALLER FOR ACCURACY
3.USE MESSAGE FORMS & FOLLOW THOUGH WITH PASSING MESSAGE TO CORRECT RECIPIENT.
Handout…
HANDLING COMPLAINTS….
1.STAY CALM2.GATHER INFO3.BE SYMPATHETIC4.OFFER TO FIND OUT
WHAT CAN BE DONE5.END CALL ON
PLEASANT NOTE
Handout…