CAGAYAN STATE UNIVERSITY- ANDREWS CAMPUS

COLLEGE OF ALLIED HEALTH AND SCIENCES – RESPIRATORY THERAPY DEPARTMENT

FUNDAMENTALS OF RESPIRATORY 1 – MS. KRISHA ANNE HIPOLITO RTRP, MPH
TRANSCRIBED FROM POWERPOINT PRESENTATION

UNIT 3 : QUALITY,PATIENT
SAFETY, COMMUNICATION
AND RECORD KEEPING
QUALITY
➢ Conscious people assume positions that
➢ The quality of a service or product refers
are the most comfortable
to the sum of its properties that serve to
➢ Bedridden patients often assume an
satisfy the needs of its consumer
upright position
➢ High quality services get high demand and
➢ In other cases, patients may have to
also become a source of pride and
assume certain positions for therapeutic
financial success for the producer.
reasons, postural drainage is applied
SAFETY CONSIDERATIONS
METHOD TO MOVE A PATIENT UP IN BED
➢ SAFETY is a very important part of WITH THE PATIENT ASSISTANCE
ensuring high- quality care
➢ Patient safety musts always be the first
considerations in respiratory care
➢ The areas of potential risk for patients,
RTs, and co workers:
➢ Patient movement and ambulation,
electrical hazards fire hazards, and AMBULATION
general safety concerns.
➢ Helps maintain normal body function
BASIC BODY MECAHNICS ➢ Extended bed rest can cause numerous
problems, including bed sores and
aletectasis
➢ Should begin as soon as the patientis
physiologically stable and free of severe
pain
➢ RTs may asssist to ambulate patients
while they are on a on O2 support

BODY MECHANICS FOR LIFTING AND SAFE PATIENT MOVEMENT STEPS

CARRYING OBJECTS
1. Place the bed on a low position and
➢ Posture involves the relationship of the lock its wheels
body parts to each other 2. Place all the equipments ( e.g,,
➢ Poor posture may place inappropriate intravenous (IV) equipment, , NGT ,
stress on joints and related muscles and surgical drainage tubes) close to the
tendon patient to prevent dislodgment during
➢ The correct technique: straight spine and ambulation.
use of the leg muscles to lift the object 3. Move the patient toward the nearest
side of bed
MOVING THE PATIENT IN BED 4. Assists the patient to sit up in bed (i.e.,
arm under nearest shoulder and one
under farthest armpit)
5. Place one hand under the patient’s
farthest knee, and gradually rotate the
patient so that his or her legs are
dangling off the bed
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CAGAYAN STATE UNIVERSITY- ANDREWS CAMPUS
COLLEGE OF ALLIED HEALTH AND SCIENCES – RESPIRATORY THERAPY DEPARTMENT
FUNDAMENTALS OF RESPIRATORY 1 – MS. KRISHA ANNE HIPOLITO RTRP, MPH
TRANSCRIBED FROM POWERPOINT PRESENTATION

6. Let the patient remain in this position PREVENTING SHOCK HAZARDS

until diziness or light headedness
lessens ( encouraging the patient to ➢ Most shock hazards are caused by
look fofrward rather than at the floor inappropriate or inadequate grounding.
➢ All equipment brought ino the patient care
may help)
7. Assists the patient to a standing has been approved and checked on a
position regular basis by a qualified expert.
8. Encourage the patient to breath easily GROUND ELETRICAL EQUIPMENT NEAR THE
and unhurriedly during this initial PATIENT
change to a standing posture
9. Walk with the patient using no, ➢ All eletrical equipment should be
minimal or moderate support connected to grounded outlets with three-
(moderate support requires the wire cords
assistance of two practitioners, one on ❖ In these cases, the third (ground) wire
each side of the patient). prevents the dangerous buildup of
10. Limit walking to 5 to 10 minutes for the voltage that can occur on the metal
first exercise. frames of some eletrical equipment
➢ Monitor the patient during ambulation ➢ Modern eletrical devices used in hospitals
➢ Note the patient’s level of conciousness, are designed so their frames are
color, breathing, stremght or weakness, grounded, but the patient remains islolated
and complaints from ground.
➢ Each session is documented in the patient FIRE HAZARD
chart
➢ The date and time of ambulation, length of ➢ Significant reduction in health care facility
ambulation annd degree of pateint fires is primarily due to education and
tolerance. enforecement of strict fire codes.
➢ Approximately 23% of fires in healthcare
ELETRCIAL SAFETY facilities occur in hospitals or hospice, and
➢ The potential for accidental shocks of 46% occur in nursing homes: most
patients or personnel in the hospital exists hospital fires start in kitchen
because of the frequent use of eletrical ➢ Fires in O2 enriched atmospheres (OEAs)
equioment are larger, more intense, faster burning,
➢ The presence of invasive device, such as and more difficult to extinguish
internal cathethers and pacemakers, may
3 CONDITIONS MUST EXIST FOR FIRE
add to the risk for serious harm from
eletrical shock TO START:
➢ RTs must understand the fundmentals of
➢ Flammable material must be present
eletrical safety because respiratory care
➢ O2 must be present and
often involves the use of eletrical devices
➢ The flamable material must be heated to
FUNDAMENTALS OF ELETRICITY or above its ignition temperature

➢ The ability of humans to create and O2 is nonflammable, but

harness eletricity is one of the most
important developments in modern times ➢ it greatly accelerates the rate of
➢ Despite the fact that eletricity is one of the combustion
most popular sources of power, most ➢ oxygen supports combustion
people who use it have a poor
PASS- FIRE EXTINGUISHER TRAINING
understanding of it.
➢ Lack of knowledge is often a major factor P- pull pin
in cases of electrocution.
A-aim nozzle
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CAGAYAN STATE UNIVERSITY- ANDREWS CAMPUS
COLLEGE OF ALLIED HEALTH AND SCIENCES – RESPIRATORY THERAPY DEPARTMENT
FUNDAMENTALS OF RESPIRATORY 1 – MS. KRISHA ANNE HIPOLITO RTRP, MPH
TRANSCRIBED FROM POWERPOINT PRESENTATION

S- squeeze handle DISASTER PREPAREDNESS

S- sweep nozzle across base fire ➢ A key component involves learning
transport and transfer critically ill patients
• if you identify a fire in a patient care area, safely and preparation of loss pf eletricity
you must know what to do. Each hospital ➢ In theses emergencies, hospitals have
must hav a core fire plan that identifies backup generators to power essentail
the rrsponsibilities equipment.
RACE- core fire plan ➢ It is important for the RT to know the
specific hospital policy foer power failures
• Rescue patients in the immediate area of and other potental disasters
the fire MAGNETIC RESONACE IMGING SAFETY
• Alert other personel`about the fire so they
can assist in the rescue and can relay the ➢ MRI exposes the body to powerful
location of the fire to officials magnetic fields and a small amount of
radiofrequency
• Contain the fire
➢ RTs need to become familiar with MRI-
• Evacuate other patients and personnel in compatibke ventilators, 02 supplies,a nd
the areas around the fire who may be in ancillary equipment
danger if th fire spreads ➢ Each radiology department has specific
❖ RTs are frequently key participants in rules and safety precautions that need to
succesful handling of hospital fires. be communicated to all patients,
For these reasons, RTs should be caregivers and health care personnel
included in all hospitals evacuation
planning and pratices MEDICAL GAS CYLINDERS

First, they know where the O2 zone valves are ➢ Use of compresses gas cylinders by RTs
requires special handling
located and how to shut them off
➢ Improper storage or handling of cylinders
Second, they have the knowledge and skills include increased risk for fire, explosive
needed to evacuate patients receiving mechanical release of high- pressure cylinders and the
ventilation or supplementantal O2 to sustain life toxic effect of some gases
➢ It is imporatant to store and transport
Third, they may know hiw to treat and resuscitate cylinders in appropriate racks or chained
victims of smoke inhalation. containers
➢ Compressed gas cylinders should never
GENERAL SAFETY CONCERNS be stored without support.
➢ RTs need to be aware of general safety
COMMUNICATION
concerns, including the direct patient
environment, disaster preparedness, ELEMENTS OF HUMAN COMMUNICATION
magnetic resonance imaging (MRI) safety,
and medical gas safety.
DIRECT PATIENT ENVIRONMENT
➢ The immediate environment arund the
patient can create risk for patient safety
➢ To reduce the risk for patient falls and
allow easy access to care, should be as
free of ipediments to care as possile
➢ When care is completed, the RT should ➢ Essential to the quality mission of a
ensure that the patient has easy access to
healthcare organization.
the patient call system
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CAGAYAN STATE UNIVERSITY- ANDREWS CAMPUS
COLLEGE OF ALLIED HEALTH AND SCIENCES – RESPIRATORY THERAPY DEPARTMENT
FUNDAMENTALS OF RESPIRATORY 1 – MS. KRISHA ANNE HIPOLITO RTRP, MPH
TRANSCRIBED FROM POWERPOINT PRESENTATION

➢ Strategies to enchance communication ➢ Receive confirmation from the “prescriber /

are critical to organization success reporter” that the information is correct:
➢ Comunication is a dynamic human incorrect, repeat the process
process involving sharing of information,
meanings and rules
➢ Five basic components: sender, message, ❖ another setting for improving
channel, receiver, and feedback communication between RTs regards
Sender- the indiv. Or group who transmits the transition of care or “hand-off” of care
message ❖ an effective communication tool is this
instance may be an SBAR (situation,
Message – the information or attitude that is background, assesment, and
communicated by the sender recommendation)
❖ as an RT,you will have many opportunities
Channel – method use to transmit messages
to communicate with patients, other
Receiver – the target of the communication members of the healthcare team
and can be an individual or a group ❖ success as an RT depends on your ability
to communicate with patients, other
Feedback- te lastv essential part of memebers of the healthcare team.
communication ❖ Success as an RT depends on your ability
COMMUNICATION IN HEALTH CARE to communicate with these key people
❖ Poor communication skills can limit your
➢ Effective communication is the most ability to treat patients, work well with
important aspect providing safe patient others , and find satisfaction in your
care employment.
➢ All health care personnel must
correctly identify patients before initiatif FACTOR AFFECTING COMMUNICATION
care using a two- patient identifier
system.
➢ Effectively communicating critical test
values should include a “read back”
scenario

“READ BACK” PROCESS TO ENSURE

ACCURATE COMMUNICATION OF
INFORMATION

PRESCRIBER/ REPORTER

➢ Order or critical test results are read and ➢ the uniquely human or “internal” qualities
clearly enuciated, using two patient of sender and receiver play a large role in
idetifiers communication process.
➢ avoid abbreviations ➢ Generally, the verbal and non verbal
➢ ask receiver to “read back” the iformation components of communication shpuld
is correct enchance an dreiforce each other.
➢ Patients direct health care environment
RECEIVER and their sensory or emtiona state
➢ The RT who considers all of these will
➢ record the order/value become a better communicator
➢ ask “prescriber/reporter” to repeat if
information is not understoos. PURPOSE OF COMMUNICATION IN
➢ “read back” the information, including two HEALTH CARE SETTING
patient identifiers
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CAGAYAN STATE UNIVERSITY- ANDREWS CAMPUS
COLLEGE OF ALLIED HEALTH AND SCIENCES – RESPIRATORY THERAPY DEPARTMENT
FUNDAMENTALS OF RESPIRATORY 1 – MS. KRISHA ANNE HIPOLITO RTRP, MPH
TRANSCRIBED FROM POWERPOINT PRESENTATION

➢ Establish rapport with another individual, ➢ Hear the speaker out before making an
such as colleague, a patient, or a member evaluation
of the patient’s family ➢ Maintain a composure; control emotions
➢ Comfort an anxious patient by explaining ACTIVE LISTENING-Is a key component
the unknown in health care communication
➢ Obtain information, such as during a 3. PROVIDING FEEDBACK
patient interview
➢ Relay pertinent information, as when To enchance communication with others,
charting the results of a patient’s effective feedback needs to be provided:
treatments
➢ Attending
➢ Give instructions, as to when teaching a
➢ Paraphrasing
patient how to perform a lung function test
➢ Requesting clarification
➢ Persuade others to take action ,as when
➢ Perception checking
attemping to convince a patient to quit
➢ Reflecting feelings
smoking
➢ Educate and confirm understanding as in MINIMIZING BARRIEIRS TO COMMUNICATION
a “teach back” scenario
A skillful communicator tries to identify and
IMPROVING COMMUNICATION eliminate or minimize the influence of these
barriers in all interactions. By minimizing the
SKILLS influence of these barriers, the sender can help
➢ To enchance your abiity to ensure that the message will be received as
communicate effectively,focus in intended
improving sending, receiving and ➢ Key barriers to effective communication
feedback skills. In addition, identify are the following:
and overcome common barriers to ➢ Use of symbols or words that have
effective communication different menanings
1. PRACTITIONER AS SENDER ➢ Different values systems
➢ Emphasis on status
Your effectiveness as a sender of messages can ➢ Conflict of interest
be improved in several ways. These suggestions ➢ Lack of acceptance of differences in points
may be applied to the clinical setting as follows: of view, feelings, values, or purposes
➢ Share information rather than telling. ➢ Feelings of personal insecurity
➢ Seek to relate to people rather than To become an effective communicator, identify
control them the purpose of each communication interaction
➢ Value disagreement as much as and your role in it.
agreement.
➢ Use effective nonverbal communicatin Use specific sending, receiving and feedback
techniques. skills in each interaction
2. PRACTIONER AS RECEIVER AND Finally, minimize any identified barriers to
LISTENER caommunication with patients or peers, to ensure
that messages are received as intended.
Receiver skills are just as important as sender
skills. Messages sent are of no value unless they CONFLICT AND CONFLICT RESOLUTION
are received as intended. A few simple principles
can healp your listening skills, as follows: ➢ Conflict is harp disagreement or
opposition among people over interests,
➢ Work at listening ideas, or values
➢ Stop talking ➢ Healthcare professionals experience a
➢ Resist distractions great deal of conflict in their jobs
➢ Keep your mind open; be objective
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CAGAYAN STATE UNIVERSITY- ANDREWS CAMPUS
COLLEGE OF ALLIED HEALTH AND SCIENCES – RESPIRATORY THERAPY DEPARTMENT
FUNDAMENTALS OF RESPIRATORY 1 – MS. KRISHA ANNE HIPOLITO RTRP, MPH
TRANSCRIBED FROM POWERPOINT PRESENTATION

➢ Rapid changes occuring in healthcare 5. Compromising

have made everyones jobs more complex ➢ Is a middle- ground strategy that combines
and often more stressful. assertiveness and cooperation
➢ Because conflict is inevitable, all health ➢ Compromise is best used when a quick
care professionals must be able to resolution is needed that both parties can
recognize its sources and help resolve or accept.
manage its effect om people and on te
organization. RECORDKEEPING

SOURCES OF CONFLICT ➢ The eletronic medical record (EMR) is

changing the way healthcare
➢ The first step in conflict management is to practitioners document care, but the
identify its potential sources overall content and concept of what we
record remains te same.
Four primary sources of conflict in organizations
➢ A medical record or chart presents a
1. Poor communication written picture of occurences and
2. Structural problems situatons pertaining to a patient
3. Personal behaviour throughout his or her stay in a health
4. Role of confict care institution.
➢ Medical records are the property of the
CONFLICT RESOLUTION institution and are strictly confidential.
➢ Conflict resolution or management is the In addition, the medical record is a
process by which people control and legal document.
channel disagreements within an ➢ For this reason, charting or
organization recordkeeping must be done so that it
is meaningful for days, months, or
Tge following are five basic strategies for years.
handling conflict
COMPONENTS OF A TRADITION
1. Competing MEDICAL RECORD.
➢ Is an assertive an uncooperative conflict
resolution strategy. ➢ Each health care facility has its own
➢ It is a power-oriented method of resolving specification for the medical records it
conflict keeps. Although the forms themselves
2. Accomodating vary among instuitions, most acure care
➢ is an assertive and uncoopeative conflict medical records share common sections.
resolution strategy ➢ Documentation can include many
➢ accomodation is a useful strategy when it measurements and review of a sequence
is essentail to maintain harmony in the of entries can reveal trends in patient
environment status
3. Avoiding
➢ Is both an unasservative and GENERAL SECTIONS FOUND IN A
uncooperative conflict resolution strategy. PATIENT MEDICAL RECORD
➢ Avoidance may be appropriate if there is
no possibility of meeting one’s goals • Admission Data
4. Collaborating ‘ • History and physical examination
➢ Is an assertive and cooperative • Health mainatenace and immunazations
➢ Collaboration usually takes more time than • Physicaians orders
other methods of conflict management • Progress notes
and cannot be applied when the involved • Nurse’s notes
parties harbor strong negative feeling • Medication record
about each other. • Allergies
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CAGAYAN STATE UNIVERSITY- ANDREWS CAMPUS
COLLEGE OF ALLIED HEALTH AND SCIENCES – RESPIRATORY THERAPY DEPARTMENT
FUNDAMENTALS OF RESPIRATORY 1 – MS. KRISHA ANNE HIPOLITO RTRP, MPH
TRANSCRIBED FROM POWERPOINT PRESENTATION

• Vital signs flowsheet i/o sheet ➢ Institutional policy may require that
• Laboratory results supervisory personnel countersign student
• Consulatation note entries in the hand written recor.
• Surgical or treatment consent ➢ Do not use ditto marks (“)
• Anethesia and surgical Record ➢ Do not erase.
• Specialized flow data ➢ Erasures provide reason for question if the
chart is used later in a court law.
• Advanced directives
➢ Record after completing each task for the
LEGAL ASPECTS OF RECORDKEEPING patient and sign your name correctly after
each entry.
➢ Legally, documentation of the care given ➢ Be exact in noting the time, effect, and
to patient means that care was given; no results of all treatments and procedures.
documentation means that care was not ➢ Chart patient cpplaints and general
given. behaviour
➢ If the RT does not document care given, ➢ Leave no blank lines in the charting
the parctitioner and the hospital may be ➢ Draw a line through the center of n empty
accused of patient neglect. line or part of a line.
➢ Adequate documentation of care is ➢ Use standard abbreviations
valuable only in referenceto standards and ➢ Use the present tense
criteria of care. ➢ Never use the future tense, as in “patient
➢ Documentation must reflect these to receive treatment after lunch”
standards. ➢ Spell correctly
➢ Document coversations with the patient or
PRACTICAL ASPECTS OF other healthcare providers that you think
RECORDKEEPING are important (e,g, you informed the
patient’s physician or nurse that the
➢ Recordkeeping is one of the most patient seems confused or more short of
significant duties that a healthcare breath).
professional performs.
➢ Documentation is required for each PROBLEM-ORIENTED MEDICAL
medication, treatment or procedure.
➢ Accounts of the patient’s condition and RECORD
activities must be charted accurately and
in clear terms ➢ It is an alternative documentation forat
➢ Brevity is essential, although a complete used by some health care institutions
account of each patient encounter is FOUR PARTS:
needed.
➢ Documentation of consultations with the 1. Database
attending physician that include the date ➢ Contains routinr inforation about the
and time of the conversation is patient
recommended 2. Problem list
➢ Assesments of data must be clearly within ➢ Something that interferes with a patient’s
one’s professinal domain physical or psychologic health or baility to
function.
GENERAL RULES FOR MEDICAL 3. Plan
RECORDKEEPING 4. Progress notes
➢ Contain the findings ( subjective and
➢ Entries on the patient’s chart should be objective data) assesment, plans, and
printed or handwriten unless the institution orders of the physicians, nurses, and other
is using an eletronic medical record practitioners involved in the care of the
patient

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CAGAYAN STATE UNIVERSITY- ANDREWS CAMPUS
COLLEGE OF ALLIED HEALTH AND SCIENCES – RESPIRATORY THERAPY DEPARTMENT
FUNDAMENTALS OF RESPIRATORY 1 – MS. KRISHA ANNE HIPOLITO RTRP, MPH
TRANSCRIBED FROM POWERPOINT PRESENTATION

➢ Wheter electronic or written, the precise

forms these records take vary among
institutions but will share common
information.

POMR PROGRESS NOTES

S- SUBJECTIVE INFORMATION

O-OBJECTIVE INFORMATION

A-ASSESMENT

P-PLAN OF CARE

RULE OF THUMB

➢ SUBJECTIVE
Information obtained from the patient his
or her family members, or a similar source
➢ OBJECTIVE
Information based on a caregivers
observations of the patient, the physical
examination, or diagnostic or laboratory
tests such as arterial blood gases or
pulmonary function tests
➢ ASSESMENT
Which refers to the analysis of the
patient’s problem
➢ PLAN of action to be taken

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