TABLE OF CONTENTS

1.Introduction to nursing /Midwifery communication………..3

2.Written communication………………………………………………………………5

2.1.Guidline for documentation and record keeping …………..5

2.2.Nursing & Midwifery process form …………………………….6

2.3.Clinical forms………………………………………………………………………………7

3.Verbal communication………………………………………………………………………………10

3.1.Reporting to physician ………………………………………………………………10

3.2.Nurse /Midwifery -to-nurse /Midwifery communication………10

3.3.Nurse /Midwifery - to- junior nurse / Midwifery report…………11

3.4.Patient education……………………………………………………………………..13

4.Physician order…………………………………………………………………………………………14

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 Introduction to Communication in Nursing /Midwifery

Communication is a process in which people affect one another through exchange

of information, ideas and feelings.

Communication should be accurate, timely and effective

It includes discussion, reports, records, orders can be oral or written

Quality of patient care depends on the caregiver’s ability to communicate

with patient and with colleagues

Responsible nursing is not simply the ability to successfully carry out a series of
routine procedures – be they taking a blood sample, dressing a wound or
administering medication. Neither is it about treating the patient purely on a
physical level. Nursing is a holistic process, taking into consideration not only the
psychological, but any socio-cultural, environmental and politico-economic
features of a disease and its treatment, not to mention the impact on patients and
their families. From a communication perspective, the following functions,
respecting confidentiality; sharing, in a way they can understand, information
people want or need to know about their health; accurate record keeping,
reinforce the fact that effective spoken and written skills are essential to the
toolkit of the responsible nurse.
It is widely accepted that building and maintaining a good patient relationship
is an essential aspect of the treatment and healing process and that effective
communication skills are key to achieving this. It also goes without saying that
patients spend more time communicating with nurses than with any other

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healthcare professional. Emphasis placed on the therapeutic nature of medicine
means that, possibly more than any other learner, non-native speaker nurses have
a very real need to communicate effectively from day one.
Communication in is a complex process of sending and receiving verbal and
non-verbal messages, it allows the exchange of information, feelings, needs, and
preferences and it uses source/sender and receiver encode and decode message
in a cyclic pattern as communication channels. There are two main types of
communication: verbal and written forms of communication:

Written communication: This includes the written documentation

of all findings, progress, care and treatment provided to the patient by the
medical team, including the nurses.

Verbal communication: the act of reporting and conversing with

other members of the health care team regarding the patient’s progress and
status.

Results of effective communication

The positive results of effective communication are well documented and are
essential in achieving, amongst others, increased recovery rates, a sense of safety
and protection, improved levels of patient satisfaction and greater adherence to
treatment options. Aside from these, successful communication through a patient-
centered approach also serves to reassure relatives that their loved ones are
receiving the necessary treatment. Within the nursing field, such skills are
considered indicative of best practice.

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The 7 Cs of Communication: A Checklist for Clear
Communication
According to the 7 Cs, communication needs to be:

Clear.
Concise.
Concrete.
Correct.
Coherent.
Complete.
Courteous.

1.Written Communication

The following items are used by nurses to document a patient’s course of

treatment. It is the nurse’s responsibility to ensure that a patient’s medical record
is complete, containing all the necessary forms in the proper sequence. The forms
are intended to guide the entire medical team and to become a permanent record
maintained in the patient’s medical record:
Guidelines for documentation and record keeping
Patient and client records should:
— be based on fact, correct and consistent
— be written as soon as possible after an event has happened to provide current
(up to date) information about the care and condition of the patient or client
— be written clearly and in such a way that the text cannot be erased (rubbed out
or obliterated)

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— be written in such a way that any alterations or additions are dated, timed and
signed, so that the original entry is still clear
— be accurately dated, timed and signed, with the signature printed alongside the
first entry
— not include abbreviations, jargon, meaningless phrases, irrelevant speculation
and offensive subjective statements
— be readable on any photocopies.
You will see lots of different charts, forms and documentation. Every hospital, care
home and community nursing service will have the same basic ones, but with small
variations that work best locally. The common documents that you will use include
some of the following.
1) Nursing/ Midwifery Process Forms: nurses should record all steps in the
nursing process on the appropriate forms:
Nursing /Midwifery Admission Assessment Form
Nursing/ Midwifery Diagnose /Problem Statement List
Nursing / Midwifery Care Plan
Nursing /Midwifery implementation
Nursing / Midwifery Patient Progress /Evaluation Report
Nursing /Midwifery assessment sheet
The nursing/ Midwifery assessment sheet contains the patient’s biographical
details (e.g. name and age), the reason for admission, the nursing needs and
problems identified for the care plan, medication, allergies and medical history.
Nursing /Midwifery care plan
The documents of the care plan will have space for:
— Patient/client needs and problems.

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— Nursing/ Midwifery diagnoses should be documented
— Planning to set care priorities and goals. Goal-setting should follow the SMART
system, i.e. the goal will be specific, measurable, achievable and realistic, and
time-oriented. Some goals, such as reducing anxiety, are not easily measured and
it is usual to ask patients to describe how they feel about a problem that was
causing anxiety.
— The care/nursing /Midwifery interventions needed to achieve the goals.
— An evaluation of progress and the review date. This might include evaluation
notes, continuation sheets and discharge plans. In some care areas you might
record progress using a Kardex system along with the care plan.
— Reassessing patient/client needs and changing the care plan as needed.
2) Clinical forms: Nurses must record patient data and findings on clinical forms
that include:
vital sign Sheet
Intravenous Fluid Administration Record,
Fluid Balance Chart
Medication Administration Record
Informed consent

Vital signs
The basic chart is used to record temperature, pulse, respiration and possibly
blood pressure. Sometimes the patient’s blood pressure is recorded on a separate
chart. Basic charts may also have space to record urinalysis, weight, bowel action
and the 24-hour totals for fluid intake and output. More complex charts, such as

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neurological observation charts, are used for recording vital signs plus other
specific observations, which include the Glasgow Coma Scale score for level of
consciousness, pupil size and reaction to light, and limb movement.
Fluid balance chart
This is often called a ‘fluid intake and output chart’ or sometimes just ‘fluid chart’.
It is used to record all fluid intake and fluid output over a 24-hour period. The
amounts may be totaled and the balance calculated at 24.00 hours (midnight), or
at 06.00 or 08.00 hours. Sometimes the amounts are totaled twice in every 24
hours (i.e. every 12 hours). Fluid intake includes oral, nasogastric, via a
gastrostomy feeding tube, and infusions given intravenously, subcutaneously and
rectally. Fluid output from urine, vomit, and aspirate from a nasogastric tube,
diarrhoea, fluid from a stoma or wound drain are all recorded.
Medicine/drug chart
It is important for you to become familiar with the medicine/drug-related
documents used in your area of practice. A basic medication record will contain
the patient’s biographical information, weight, history of allergies and previous
adverse drug reactions. There will be separate areas on the chart for different
types of drug orders. These include:
— drugs to be given once only at a specified time, such as a sedative before an
invasive procedure
— drugs to be given immediately as a single dose and only once, such as adrenalin
(epinephrine) in an emergency
— drugs to be given when required, such as laxatives or analgesics (pain killers)
— drugs given regularly, such as a 7-day course of an antibiotic or a drug taken for
longer periods (e.g. a diuretic or a drug to prevent seizures). All drugs, except a

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very few, are ordered using the British Approved Name, and the order (or
prescription) will include the dose, route, frequency (with times), start date and
sometimes a finish date. There is space for the signature of the nurse giving
the drug and. It is vital to record when you give a drug. This is done at the time so
that all staff know that it has been given, and do not repeat the dose. Likewise, if
you cannot give the drug for some reason (e.g. patient is in another department or
their physical condition contraindicates giving the drug), make sure that this fact is
recorded on the medicine/drug chart and the doctor is informed if necessary.
Remember that in some situations you will need to record in the nursing notes
when you give patients a drug (e.g. if you give analgesic drugs (pain killers)).
Informed consent
Responsibility for making sure that the person or the parents of a child have all the
information needed for them to give informed written consent rests with the
health practitioner (usually a doctor or nurse) who is undertaking the procedure or
operation. This information will include:
information about the procedure/operation
the benefits and likely results
the risks of the procedure/operation
the other treatments that could be used instead
that the patient/parent can consult another health practitioner
that the patient/parent can change their mind.
Young people can sign the consent form once they reach the age of 16 years
and/or have the mental capacity to understand fully all that is involved. If the
young person cannot sign the form, the parent or legal guardian may sign it. If an
adult lacks the mental capacity, either temporarily or permanently, to give or deny

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consent, no person has the right to give approval for a course of action. However,
treatment may be given if it is considered to be in the person’s best interests, as
long as an explicit (clear) refusal to such action has not been made by the person
in advance. The patient or parent and the healthcare practitioner both sign the
consent form. When your patients are due to have any invasive procedure, always
check their level of understanding before it is scheduled to happen. If you are not
sure about answering a question, ask the healthcare practitioner who is doing the
procedure to see the patient and explain again.

Verbal Communication

1) Reporting to Physicians: Whenever a patient’s status changes, the

physician should be informed. The status should be reported in an objective
manner, allowing for the physician’s recommendation(s). Any physician’s order
should then be documented in the medical record by the nurse as a verbal order.
Verbal orders from a physician to a nurse must be told to 2 nurses simultaneously
in order to ensure that instructions are clearly understood and verifiable. The
transcribed order should be signed by the physician within 24 hours.
2) Nurse/ Midwifery -to-Nurse /Midwifery Report: During a shift change, the

off-going nurse should verbally report to the on-coming nurse concerning the
status of each patient using a standard format. The report consists of a general
synopsis of the patient, any significant events during the shift, as well as a progress
report of the work completed. Updates should be provided on IV administration,
tests done or pending, abnormal laboratory findings, and general patient progress.

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 Follow the format below for performing nurse-to-nurse shift report.
Patient name
Patient age
Reason for Seeking Care/Chief complaint
Patient diagnosis: present all current diagnoses
Current IVs
Tests completed or pending
Abnormal lab findings: do not report normal findings
Events during the shift: synopsis of what occurred during the shift
Patient progress: description of patient’s response to any treatment or
events that occurred during the nurse’s shift, including the patient’s
progression towards discharge.
3) Nurse /Midwifery to Junior Nurse/Health Assistant/Student Report: At the
start of each shift, the nurse is responsible for reporting to the junior nurse/health
assistant/student regarding patient(s) under his/her care. Specific care information
related to bathing, ambulating, eating, toileting, and other similar concerns should
be discussed. A written checklist of tasks to be completed should be given to the
junior nurse/health assistant/student.
Use the following format for performing a nurse to junior nurse/health
assistant/student report. It is important that the assigned tasks are specific to
ensure that the junior nurse/health assistant/student is able to accomplish them
during their shift.

Vital Signs: Describe the frequency required for assessing a patient’s vital signs.
Is it necessary to assess them:

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 Once a shift,
Twice a shift,
Every hour, or
Other unique needs.

Bathing: Describe the level of assistance the patient requires for bathing and
changing linens. Is the level:
Complete assistance during both bath and bed linen changing,
Required assistance when bringing bathing materials to the patient who
must remain in the bed while linens are changed,
Required assistance when bringing bathing materials to the patient who is
capable of getting out of the bed while the linens are changed, or
No assistance necessary because the patient is independent during bathing
and the patient is capable of getting out of bed while the linens are changed.

Activity: Describe the activity level of the patient as follows:

Bed rest: how often does the patient need to be turned?
Out of bed (OOB) walking: is the patient OOB at will or does he/she need
assistance? If assistance is required, please inform the aide of the frequency of
OOB.
Out of bed (OOB) to chair: what is the level of assistance required to get OOB to
a chair? If assistance is required, please inform the aide of the frequency that
this should occur and for how long.

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 Toileting: Describe the level and type of assistance the patient requires to
perform the following (if applicable):
Out of bed to the bathroom,
Offer the bedpan to the patient every ________ (amount of time),
Patient uses the urinal,
Patient has a Foley catheter, and/or
All patient output should be recorded and communicated.

Diet: Describe the patient’s type of diet and the assistance they require:
Set up the food only,
Set up and cut the food,
Feed the patient, and/or
Record all input.
Safety: Describe how often the aide needs to make rounds on the patient.
4) Patient Education: It is important to educate the patient, his/her
spouse/partner, and his/her family about the illness and course of treatment being
provided as a preventative and/or curative measure. It informs and empowers the
patient, thus improving his/her ability to achieve a higher level of wellness and
ability to manage specific needs. Efforts to educate the patient should be realistic,
relevant and provide time for patient practice and opportunity to seek clarification.
Patient education should also incorporate family members and other caregivers
who often play strong role in facilitating patient care in coordination with medical
staff. One suggestion to improve the family and staff relationship is through the
use of a Patient Caregiver Contract, whereby the relationship is formalized between
families/caregivers and medical staff. This allows patient families to act as “aides”

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and provide certain services (feeding, bathing, ambulating, bringing fresh sheets
and food, etc.) within guidelines that are acceptable to medical staff. Such a
formalized process can greatly improve the patient’s quality of care. It is also
important to ensure that such a contract is fully understood by both the patient
and caregiver prior to signing.

Physician orders

Physicians provide both written and verbal forms of communication in order to

direct a patient’s care. It is the nurse’s responsibility to ensure that a physician’s
orders and plan for a patient’s care are put into action.
Physician’s orders should be recorded by the physician on a Physician Order Sheet.
When the order is carried out this should be documented on the order sheet,
including the date and time that the order was carried out, and the signature of
the person confirming that the order has been completed.
All physician orders, even verbal orders, must be documented.
Any/all verbal orders from a physician must be given to two (2) nurses
simultaneously in order to ensure verbal instructions are clearly understood and
verifiable. The physician should be clear about which nurse (of the two) is to
implement his/her verbal orders. Once received, the order is immediately
transcribed into the Physician Order Sheet by the implementing nurse. The nurse
who is writing the order completes the transcription by writing “verbal order given
by (the name of the physician)/the nurse’s signature.” All verbal orders are to be
reviewed and co-signed by the physician within twenty-four (24) hours.

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