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Badly written notes can cause many issues in a medical office. Patients may think that we don't not care about them and that can leave them also thinking that we are unprofessional. Here are some steps that I can take to ensure that my written communication is clear is: Think out what needs to be written down before actually writing it down. When writing, make sure that each word and sentence is clear and organized. Always use a black pen unless something needs to be done STAT. Do not use black gel pens because they tend to smear very easily. If using abbreviations, make sure that they are correct. Word choice is very important for good, effective communication. When someone does not pick their words wisely while talking to the patients, it can make the patients feel like they should not be the person taking care of them because they are not professional. It also makes the patients feel like they do not know what they are doing. As a Medical Assistant, it is my responsibility to ensure my communication is clear and written properly. If my notes are not organized and written clearly, not only will the patient think in unprofessional, the doctor's will too. Also, if I use abbreviations, I need to make sure that they are correct. Some abbreviations look very similar to others so things can get confused very easily. …show more content…
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Ramkissoon Badly written notes can cause many issues in a medical office. Patients may think that we don't not care about them and that can leave them also thinking that we are unprofessional. Here are some steps that I can take to ensure that my written communication is clear
is: Think out what needs to be written down before actually writing it down. When writing, make sure that each word and sentence is clear and organized. Always use a black pen unless something needs to be done STAT which is written in red ink. Do not use black gel pens because they tend to smear very easily. If using abbreviations, make sure that they are correct. Word choice is very important for good, effective communication. When someone does not pick their words wisely while talking to the patients, it can make the patients feel like they should not be the person taking care of them because they are not professional. It also makes the patients feel like they do not know what they are doing. As a Medical Assistant, it is my responsibility to ensure my communication is clear and written properly. If my notes are not organized and written clearly, not only will the patient think in unprofessional, the doctor's will too. Also, if I use abbreviations, I need to make sure that they are correct. Some abbreviations look very similar to others so things can get confused very easily. I definitely agree with everything you said about communication with patients in handwritten notes. I also really like what you said about the responsibility of a medical assistant. I like how you gave the example of writing in all caps. I also really like how you have the different types of communication listed. I agree that working in the medical field, we need to be formal. It is very important to remain professional and polite.
Communication is cited as a contributing factor in 70% of healthcare mistakes, leading to many initiatives across the healthcare settings to improve the way healthcare professionals communicate. (Kohn, 2000.)
Use non-verbal communication such as gesture, facial expression and written communication wherever possible; use pictures, symbols or music to support communication and understanding; not finishing an individual’s sentence unless asked to :avoid negative statements; take care with tone of voice and body language ; be aware of any hearing , visual or second language difficulties; use listening skills to interpret intended meaning
One of the main expectation from all Nurses and Midwives as laid down in the NMC Code of Conduct (2008) is that all Nurses and Midwives must keep clear and accurate records. The Department of Health’s (DH) policy statement on record keeping also place a responsibility on all health professionals to ensure that all records created and maintained are accurate, current, comprehensive, concise and legible. Such records should also provide information concerning the condition, treatment and care of the patient and associated observations (DH 2002).
First, briefly state your purpose by indicating what you'd like to cover and why it's important. If you are initiating feedback, this focus gives the other person a heads up about how the conversation will go. If the other person has requested feedback, a focusing statement will make sure that you direct your feedback toward what the person needs. Always be clear and straight-to-the-point.
Healthcare professionals in the medical office should be friendly and open. Patients entering the medical office should be greeted immediately with a smile and having a gentle touch also let the patient know you care. “Healthcare professionals in a medical office are held to a higher standard than most professions because they are dealing with the dignity of patients and the ability to be healed” (Wolff). Educating the staff to be professional in the medical office represents the office as being excellent in patient care. Patient-centered care success is required by the whole office which is treatment and patient experience, from the time they enter the office until they leave.
Language can be an example of poor documentation practices in patient records because it has to be specific, objective, and factual. An example would be a nurse documenting about a patient “appearing to be looking good” the nurse was using vague words and speculating. There needs to be specific facts that the patient is doing well by documenting the patient’s temperature or the reaction to the medication taking affect. Vague words can cause problems to the healthcare provider because the nurse didn’t describe facts and the provider needs facts to prove that the patient is doing well and not send them home still feeling ill. This could cause problems with the patient because the patient may be feeling the opposite and feel ill instead of good.
...eat thing when they are used properly, but it is very important that the person using them knows when they should and should not be used. There are things that can be done to try reducing risks that are associated with the misuse of abbreviations. Although Eliminating all medical abbreviations would definitely help get rid of all the problems that follow, it does not have to be the only choice in the matter of reducing the risks. Making sure that all health care personnel follow the written policies that are in place is a very important part of working in the medical field. Accreditation agencies are now starting to compose lists of all the abbreviated terms that should not be used any more. Finally, abbreviations are an important part of any medical professional's life, but when it comes to handwritten documents it is often more of a nuisance rather then a blessing.
In the provision of a high quality care, many factors influence the way it is provided; however, IC is crucial. A healthy work environment would result from open communication among the staff, it would increase the employees and patients’ level of satisfaction and sense of well-being. Good communication is the cornerstone for the IC, it is a complex process which requires to develop some skills to learn how to transmit some information. One of the most common factors leading to medical errors, are due to miscommunication, sometimes because the message is not clearly sent, and others because it is not clearly received or it is misunderstood (Danna, 2015). In terms of communication non-verbal communication must be taken into consideration as well; body language, facial expressions, use of space, and touch, entail conscious or unconscious movements and gestures, also impacts the communication among the staff and
These are Verbal, Non-Verbal and Written communication. Verbal communication refers to spoken contact between individuals, Non-Verbal is unspoken communication such as body language and written communication that uses a different pathway such as a letter. The success of verbal communication is dependent on precise, well defined, clear and age appropriate contact (RCN 2015). For example, a paediatric patient’s diagnosis may be approached with a less detailed account of the illness, thus not to confuse the individual or provoke fear. Furthermore non-verbal communication constructs a large percentage of paediatric nursing cases, due to circumstances where verbal communication is not possible. Patient-oriented care is vital for growing an understanding of the individual’s non-verbal signs of pain, which expressed the importance of actively looking for distress signals (Mattsson 2002). Finally written communication acts as the record keeping and documentation element of nursing care, which is a fundamental skill for all medical staff (NMC 2002). Incorrect written communication can lead to individual missing key changes in a patient’s condition thus leading to a potential fall in a patient’s health (Inan and Dinc
The health information communicated by an organizations staff, such as the physicians and nurse practitioners, should reflect communication techniques that focus on and emphasize the effects that low literacy can have on a patients health outcome. When considering the navigational, cognitive, and social set of language skills needed to function in a healthcare environment, organizations must ensure that the style and degree of communication deployed is sensitive to the literacy levels which they anticipate and are presented with daily. Strong communication skills deployed by a provider are a critical component
McCarthy et al. (2012) conducted a study in the United States (US) gaining patient feedback to help develop educational materials they received upon discharge from the ED. Focus groups were used with 60 people to ensure appropriate literacy and patient centred education is received. They concluded that to be able to use plain language with patients on a daily basis is difficult as it requires great skill to ensure patients from all backgrounds comprehend information (McCarthy et al., 2012). McCarthy et al. (2012) also reported that removing unnecessary words and distractions, this increased the likelihood of retaining key information. Readily understood language that engaged the audience and was displayed in an organised manner aided in the probability of patients remembering information. “Written communication is in plain language if its wording, structure,
During my past couple of weeks at Zarephath, I have continued to take vital signs and note patient symptoms and complaints, but I have additionally had the chance to be involved with the clerical aspect of patient care. I have learned that it is imperative to stay organized or one will quickly get overwhelmed—over three hundred patients equates to over three hundred files. Accidentally misplacing a single file can be pretty catastrophic; one time, this one patient’s file was not where it should have been alphabetically so I spent over 30 minutes looking for it with no luck. Essentially, if a volunteer there accidentally places a file in the wrong place, it is lost forever. The importance of organization in clinical care cannot be emphasized
She says the best description of my communication style would be assertive. She stated that when it came to work and the way I spoke to customers that I tend to be very confident when presenting customer information, even if I do not have that much knowledge of certain procedures. She added that I am also a very attentive listener and remember what the customer needed to get done while conversing about another topic as I processes their transaction. She explains how that can be a great asset when it comes to the banking world, but I just need to me more caution with certain information. The only critique she provided was to work on my wording and phrasing. She said I should choose selective words that make an unfavorable situation into one that would a favorable
As part of my on-going study and trainingin foundation degree in health and social care I was allocated to work in one of the challenging wards in University college hospital. In admitting patients, manual or paper and electronic records are being used. Electronic recording is used to put the patient’s details in the data base of the hospital and a patient hospital number is created during this process. Manual recording is done on paper and it should be written in black ink and a 24 hour clock should be used in doing an entry on either manual or electronic recording. It is also important that every page within the documentation must include the patient’s details particularly, the name, hospital number and date of birth. A sticker label in some cases is done mainly because it’s much conve...
Written communication engages any kind of interface that draws on the written word. Communication is a key to any endeavour involving more than one individual. Communicating throughout writing is fundamental in the modern world and is flattering increasingly so as we play a part in what is now frequently entitled the information age. If truth be told, written communication is the most ordinary form of business communication. It is fundamental for small business owners and managers to enlarge efficient written communication skills and to persuade the equivalent in all subordinates. The information age has transformed the ways in which we converse and located a rising prominence on written versus oral communications.