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