PART 1

• Why is effective communication among health professionals vital?


  It is vital to the quality of client care.
• How do health personnel generally communicate?

  Through discussion, reports, and records.
• What is a discussion in the context of healthcare communication?

  An informal oral consideration of a subject by two or more health care personnel to identify a problem or establish strategies to resolve a problem.
• What is a report in healthcare communication?


  Oral, written, or computer-based communication intended to convey information to others.
• What is a record in healthcare?

  also called a chart or client record, is formal, legal document that provides evidence of a client's care and can be written or computer based
• What is the process of making an entry on a client record called?

  Recording, charting, or documenting.
• What is the nurse's duty regarding patient information?

  To maintain confidentiality of all patient information.
• Who has access to a client's record?

  Health professionals involved in giving care to the client.
• Who owns the client's record?

  The institution or agency is the rightful owner of the client's record.
• What is the ethical responsibility of students and graduates regarding client records?

  To hold all information in confidence.
• How should a student or health professional protect a client's privacy?

  By not using a name or any statements that would identify the client.
• What are the guidelines for quality documentation and reporting?

  • Factual: Descriptive, objective information about what a nurses sees, hears, feels and smells. nurse. An objective description is the result of direct observation and measurement.
  • Accurate: Use of exact measurements establishes accuracy.
  • Complete: must be complete, containing appropriate and essential information.
  • Organized: Communicate in a logical order.
  • Current: timely entries are essential in a patient's ongoing care
• What is a factual record in healthcare documentation?

  A record containing descriptive, objective information about observations.
• Why is accuracy important in healthcare documentation?

  The use of exact measurements establishes accuracy.
• What does it mean for documentation to be complete?

  It must contain appropriate and essential information.
• How should information be organized in documentation?

  Communicate information in a logical order.
• Why are current entries essential in patient care documentation?

  Delays in documentation lead to unsafe patient care.
• What activities should be documented at the time of occurrence?

  Vital signs, pain assessment, administration of medications, and preparation for diagnostic tests.
• What are the purposes of client records?

  • Communication
  • Planning client care
  • Auditing health agencies
  • Research
  • Education
  • Reimbursement
  • Legal documentation
  • Health care analysis
• How do client records facilitate communication among health professionals?

  They prevent fragmentation, repetition, and delays in client care.
• What is an audit in the context of healthcare records?

  A review of client records for quality assurance purposes.
• How can client records be valuable for research?

  They can provide data for treatment plans of clients with similar health problems.
• How do students in health disciplines use client records?

  As educational tools to gain a comprehensive view of the client and illness.
• Why is documentation important for reimbursement?

  It helps a facility receive payment from the government by providing correct diagnosis codes.
• What is the principle of moral discernment?


  It involves discerning which goals and means are conducive to human fulfillment.
• What are the four principles of moral discernment/judgment?

  1. Principle of formal cooperation
  2. Principle of material cooperation
  3. Principle of lesser evil
  4. Principle of double effect
• What is the principle of formal cooperation?


  It occurs when someone intentionally helps another person carry out a sinful act.
• What is the principle of material cooperation?


  Material cooperation is immediate when the object of the cooperator is the same as the object of the wrongdoer.
• What does the principle of lesser evil state?


  When faced with two immoral options, the least immoral one should be chosen.
• What is the principle of double effect?


  It is permissible to cause harm as a side effect of bringing about a good result.
• What is the principle of well-formed conscience?


  It must consider the complementarity of faith and reason.
• What are the three functions of conscience?

  1. Feelings of what we ought to do
  2. Feelings of self-approval when we do it
  3. Feelings of remorse when we don't
• What are the strategies of the moral decision-making process?

  1. Recognizing your circumstances
  2. Seeking outside help
  3. Questioning your own and others' judgment
  4. Dealing with emotions
  5. Anticipating consequences of action
  6. Analyzing personal motivations
  7. Considering the effects of actions on others
• Recognizing your circumstances


  thinking about origins of problems, individuals involved, and relevant principles, goals & values; considering one's own role in causing and/or resolving the problem
• Seeking outside help


  talking with a supervisor, peer, or institutional resource, or learning from other's behaviors in similar situations
• Questioning your own and other's judgement


  side wrong problems that people often have with making ethical decisions, remembering that decisions are seldom perfect
• Dealing with emotions


  assessing and regulation emotional reactions to the situation
• Anticipating consequences of action


  thinking about many possible outcomes such as consequences for others, short & long term outcomes based upon possible decision alternatives
• Analyzing personal motivations


  considering one's own biases, effects of one'e values and goals, how to explain/justify one's actions to other, & questioning ability to make ethical decisions
• Considering the effects of actions on others


  being mindful of others' perceptions, and the impact of your actions on others, socially and professionally