Communicating through med record

Telephone

Triage

medical record

Guidelines

changes in health

pt communication

treatment received

chief complaint

doctors evaluations

caregivers and staff to communicate about a pt

no blank spots

own observations and actions only

neat handwriting

do not erase, cover up, or cross out mistakes

black + blue ink only

correct spelling

terminolgy

sign name & title @ end of entry

Most common form of communication

avoid eating, drinking, or chewing gum

harder than face to face

moderate speed

answer with a smile

answer phone ASAP

take callback number

ask for permission to put on hold

standard greeting

caller's name

severe pain

date + time of call

ask series of questions

signature or initials

urgency to wounds or illnesses to decide the order of treatment of a large number of patients or casualties

message is directed towards

chest pain

beware to true emergencies

remain calm

short description of caller's question

Vomiting & diarrhea