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21 Cards in this Set
- Front
- Back
record the assessment of the patient’s condition before, during, and after the treatment |
Patient Notes |
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refers to the first or earliest assessment |
Initial Notes |
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refer to the assessment reports done in order to monitor the condition of the patient |
Interim or Progress Notes |
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which are the reports given once a medication is discontinued or the patient is released from the hospital |
Discharge Notes |
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is one way of organizing patient notes |
SOAP Format |
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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) |
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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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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 |
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Is a persuasive summary of your qualifications for employment. |
Resume |
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Serves as a formal introduction of yourself to your prospective employer. |
Application Letter |
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Features of an Application Letter |
1. Qualification 2. Pleasing Tone 3. Format |
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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 |