Communication In The Health Team

Communication is the exchange of information- a message sent is received and interpreted by the intended person. Words must have the same meaning for both the sender and the receiver of the message. Try to avoid words with more than one meaning. Use familiar words when communicating. Try to be brief and concise. Do not add unrelated or unneeded information. You must stay on the subject, avoid wondering in thought, and not get wordy. Being brief and concise reduces the possibility of omitting important details.

Give information in a logical and orderly manner. Organize your thoughts so you can present them logically and in sequence. Think about what happened step by step.

Present facts and specific when giving information. Give the receiver a clear picture of what you are communicating.

The Medical Record (chart) is a written account of a person’s illness and responses to treatment and care.

It provides a way for the health team to communicate information about the person. The record is permanent and can be retrieved years later if the person’s health history is needed.

The record is a legal document. It can be used in court as evidence of the person’s problems, treatment, and care.

The record has many forms organized into sections for easy use. Each page is stamped with the person’s name, room number, and other identifying information. This helps prevent errors and improper placement of records.

The record includes:
– history
– physical examination results
– doctor’s orders
– doctor’s progress notes
– graphic sheet
– x-ray examination reports
– IV therapy record
– respiratory therapy record
– consultation reports
– surgery and anesthesia report
– admission sheet
– other reports (e.g., physical therapy, occupational therapy, speech therapy)
– special consents

Health team members record information on the forms for their department and service. The information is read by other health team members who need to know the care provided and the person’s response.

Each agency has policies about the contents of medical records and who has access to them. Policies state how often to make recordings and who records on the specific forms. Policies address acceptable abbreviations, how to correct errors, the color of ink to use, and how to sign entries.

You need to know your agency policies. All professional involved in the person’s care have access to the medical record. Those not directly involved usually cannot review the person’s record.

If you have access to medical records, you must keep the information confidential. This is an ethical and legal responsibility.


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