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21 Cards in this Set

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record the assessment of the patient’s condition before, during, and after the treatment

Patient Notes

refers to the first or earliest assessment

Initial Notes

refer to the assessment reports done in order to monitor the condition of the patient

Interim or Progress Notes

which are the reports given once a medication is discontinued or the patient is released from the hospital

Discharge Notes

is one way of organizing patient notes

SOAP Format

Meaning of SOAP

Subjective (assessment given by the family member or patient himself)


Objective (assessment seen by you or reflected in laboratory or other medical reports)


Assessment (diagnosis)


Plan (procedures to be done to address the diagnosis)


10 Nurse Communication Skills for Success

1. Non Verbal Communication


2. Active Listening


3. Personal Relationships


4. Inspire Trust


5. Show Compassion


6. Cultural Awareness


7. Educating Patients


8. Written Communication


9. Presentation Skills


10. Verbal Communication

You can communicate a powerful message without saying a word. Communication skills include making eye contact and controlling the tone of your voice. Appropriate body language, posture, and simply adding a smile can go a long way in nurse communication with both patients and colleagues.

Non Verbal Communication

Listen to understand; not solely to respond. When speaking to a colleague or patient, lean forward and nod your head to let them know you are engaged. Maintain eye contact. Carry your body in a relaxed posture; do not cross your arms.

Active Listening

With practice, you can learn to show care, compassion, and kindness while obtaining and providing information to patients. You must be able to demonstrate a level of interest in the collaborative relationship. This will help the patient feel accepted and build their trust in you.

Personal Relationships

Always keep your word. Never make promises you may not be able to keep. When you are with a patient, be present. Listen to your patients and take all their complaints or concerns seriously.

Inspire Trust

Treat patients with respect and dignity. Being in the hospital can be scary. Patients may feel depressed, helpless or even frightened. Put yourself in the shoes of your patient. Doing so will help you convey empathy while using your nurse communication skills.


Show Compassion

Every patient is unique. They may come from different countries, cultures or religions. Common practices and gestures are not accepted by all cultures.

Cultural Awareness

This nurse communication skill is at the heart of nursing. You must be able to explain disease processes, medications, and self-care techniques to patients and their families. Break down medical jargon into simple terms. Education should be collaborative. Ask patients questions and use teach-back techniques when possible.

Educating Patients

This is essential for nurse-to-nurse communication. Always ensure it is concise and easy to understand. Write in complete sentences that are grammatically correct. Only use approved abbreviations and terminology that is universal.

Written Communication

Nurses in leadership positions are not the only ones who need this skill. You may be asked to present to nurses or other staff members on a small or large scale. Plan your message. Create pleasing visual aids that add value to the presentation. Know your audience and understand what they want from your presentation.

Presentation Skills

Are of the utmost importance. Always consider your audience. Speak in clear, complete sentences and consider your tone when speaking. Nurse communication skills are indispensable to your success as a nurse, and with practice, you can become a nurse communication expert!


Verbal Communication

Is a persuasive summary of your qualifications for employment.

Resume

Serves as a formal introduction of yourself to your prospective employer.

Application Letter

Features of an Application Letter

1. Qualification


2. Pleasing Tone


3. Format

Guidelines in Writing an Application Letter

1. Focus


2. Stay on topic


3. Think of your letter as an argument


4. Choose an appropriate salutation


5. Proofread