Communicating Effectively with Healthcare Providers

Transcription

1 Communicating Effectively with Healthcare Providers Presented by: APS Healthcare Southwestern PA Health Care Quality Unit (APS HCQU) August 2011 cap Disclaimer Information or education provided by the HCQU is not intended to replace medical advice from the consumer s personal care physician, existing facility policy, or federal, state, and local regulations/codes within the agency jurisdiction. The information provided is not all inclusive of the topic presented. Certificates for training hours will only be awarded to those attending the training in its entirety. Attendees are responsible for submitting paperwork to their respective agencies. 2 1

2 Objectives Recognize role caregivers play before, during, and after medical appointments List pertinent information to report to physician State ways to increase comfort for individual at appointment 3 Advocate What is an advocate? 4 2

3 Definition of Advocate Someone who supports or speaks in favor of something Someone who acts or intercedes on behalf of another 5 Advocacy Positive relationship is established Information and concerns are communicated Report, document to ensure doctor s orders are followed 6 3

4 Importance of Documentation and Reporting Level of activity Appetite Bowel and bladder habits Usual behaviors Sleep patterns Seizure activity 7 Activity One afternoon, Mary, who is not able to communicate her needs verbally, refuses to eat lunch and has been continuously rubbing her abdomen and pacing the floors. 4

5 Gather Facts and Questions for Appointment Speak to individual Confer with other staff members Read documentation and gather facts Write down all information to take to appointment 9 Necessary Information for All Appointments Personal Information Diagnosis Current medications and dosages Allergies Reason for appointment 10 5

6 Information for First Appointment Signs/Symptoms Length of Illness Treatment and effectiveness Reason for referral from PCP 11 Information Specific to Healthcare Specialists Cardiologist: vital signs, activity level Dentist: signs of discomfort when eating, chewing; bleeding gums Dermatologist: location and description of skin problem Endocrinologist: height, weight, appetite, activity level Gastroenterologist: diet, appetite, height, weight 12 6

7 Information Specific to Healthcare Specialists Gynecologist: Last menstrual period, change in menstrual flow, discomfort with menses Neurologist: Seizure Record Ophthalmologist: Send glasses with individual on appointment Podiatrist: Location and description of foot or toenail problem Urologist: Description or chart of problems with urination 13 Psychiatrist Appointment Description of usual behavior and routine Why is individual being evaluated today Routine visit / Medication Check Exhibiting challenging behavior What exactly happens How often episodes occur Triggers De escalation techniques that are utilized Describe exactly what is observed 14 7

8 Information for Follow up Appointments Are there any changes? Are changes better or worse? Has the treatment been effective or ineffective? Were all recommendations from the last appointment followed? If not, why? Are results of tests and blood work attached to form? 15 Helping the Individual Prepare for an Appointment Explain what may occur Rehearsal Guides Ask for first appointment of day Caregiver who knows individual well should accompany to appointment Wear comfortable clothing Bring quiet activities individual enjoys Bring agency form with information 16 8

9 Advocacy at Appointment Encourage individual to Answer questions from doctor Express concerns Ask questions 17 Caregiver s Role at Appointment Answer questions Ask questions Take notes 18 9

10 After the Appointment: When to Call Doctor Unanswered questions Orders for treatment Medication questions Results from tests Symptoms worsening Make follow up appointment 19 Utilize Other Healthcare Professionals Nurse Pharmacist Dietician 20 10

11 Summary Keep lines of communication open Get the most out of appointment Ensuring optimal health care for the individual 21 Suggested Accompanying Trainings Physical Symptoms: Describing, Reporting, Documenting 22 11

12 References Communicating with Your Doctor, (2001), Family Caregiver Alliance. Retrieved August 1, 2011 from ied=678 Communicating with Your Physician: Get the Most Out of Your Appointment, Benson, D. (2010, November 29), Baylor College of Medicine. Retrieved August 15, 2011 from 23 To register for future trainings, or for more information on this or any other physical or behavioral health topic, please visit our website at

13 25 Evaluation Please take a few moments to complete the evaluation form found in the back of your packets. Thank You! 26 13

14 Test Review There will be a test review after all tests have been completed and turned in to the Instructor

15 COMMUNICATING EFFECTIVELY WITH HEALTHCARE PROVIDERS ASSESSMENT FORMS Name: Date: Recent vital signs: Temp: Pulse: Resp: BP: GI ASSESSMENT: Problem area Does the individual receive treatment for this problem? Y/N If yes, what is the treatment? Date the problem started? Is the individual complaining of nausea? Y/N Vomiting? Y/N Diarrhea? Y/N Constipation? Y/N Date of last BM Was the individual checked for an impaction? Y/N Were new medicines recently started? Y/N If yes, what were they? Was the individual started on a new diet? Y/N If yes, what is the diet? When did it start? Is the abdomen soft or hard? (circle one) Does the individual have bowel sounds? Y/N/unknown 1

16 COMMUNICATING EFFECTIVELY WITH HEALTHCARE PROVIDERS ASSESSMENT FORM Name: Date: Recent vital signs: Temp: Pulse: Resp: BP: NEURO ASSESSMENT: Problem area: Does the individual have a history of similar problems? Y/N Is the individual being treated for this problem? Y/N If yes, what is the treatment? Have medications recently been changed? Y/N Dosage of current medication: Date of last blood levels: Results of blood levels: Date of last neuro appointment: Does individual have seizures? Y/N If yes, how frequently? How long do they last? 2

17 COMMUNICATING EFFECTIVELY WITH HEALTHCARE PROVIDERS ASSESSMENT FORM Name: Date: Recent vital signs: Temp: Pulse: Resp: BP: SKIN ASSESSMENT: Problem area Does individual receive treatment for this problem? Y/N If yes, what is the treatment? Has the problem recently changed? Y/N Date problem noted: Has individual recently received any new medications? Y/N New soaps? Y/N New foods? Y/N If yes, what were they? Are any other symptoms associated with this problem? Y/N If yes, what are they? 3

18 COMMUNICATING EFFECTIVELY WITH HEALTHCARE PROVIDERS ASSESSMENT FORM Name: Date: Recent vital signs: Temp: Pulse: Resp: BP: RESPIRATORY ASSESSMENT: Problem area: When did this problem develop? Does the individual have a history of similar problems in the past? Y/N Is the individual receiving and treatment for this problem? Y/N If yes, what is the treatment? Does the individual take medications as prescribed? Y/N What medication is the individual currently taking for this condition? Have medications been changed recently? Y/N If yes, what has changed? Has the individual had recent lab values drawn? Y/N If yes, what were the results? Does the individual use oxygen? Y/N Use a nebulizer? Y/N 4

19 COMMUNICATING EFFECTIVELY WITH HEALTHCARE PROVIDERS ASSESSMENT FORM M Name: Date: Recent vital signs: Temp: Pulse: Resp: BP: EYES, EARS, NOSE AND THROAT ASSESSMENT: Problem area: Date problem occurred? Is there redness? Y/N If yes, where? Swelling? Y/N If yes, where? Drainage? Y/N If yes, from where? Color? Odor? Pain? Y/N If yes, intensity? (circle one) Mild Moderate Severe Has the individual been treated for this problem before? Y/N If yes, when? 5

20 COMMUNICATING EFFECTIVELY WITH HEALTHCARE PROVIDERS ASSESSMENT FORM Name: Date: Recent vital signs: Temp: Pulse: Resp: BP: Urinary Assessment: Problem Area Does the individual have a history of this problem in the past? Y/N If yes, when was the last occurrence? How was this treated? What are the current abnormalities? Urine color Urine odor Sediment present? Does the individual have a catheter? Y/N If yes, when was it last changed? Does the individual drink fluids adequately? Y/N 6