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Communicating through med record (Triage (caller's name, severe pain,…
Communicating through med record
Telephone
Most common form of communication
answer phone ASAP
take callback number
ask for permission to put on hold
standard greeting
avoid eating, drinking, or chewing gum
harder than face to face
moderate speed
answer with a smile
Triage
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
medical record
changes in health
pt communication
treatment received
chief complaint
doctors evaluations
caregivers and staff to communicate about a pt
Guidelines
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