MANAGEMENT AND HEALTHCARE ETHICS

LECTURE 2: PATIENT SAFETY, COMMUNICATION AND RECORDKEEPING

PROF. RITCHE L. CABURNAY, RTRP, RPSGT, MHA, CHA.
1ST SEMESTER A.Y. 2022 – 2023
Patient safety • Extended bed rest can cause numerous
• Respiratory Therapist share the general problems, including bed sores and
responsibilities for providing a safe and atelectasis (low lung volumes).
effective health care environment with • Should begin as soon as the patient is
nurses and other members of the health physiologically stable and free of severe
care team. pain.
• These responsibilities include basic patient
safety and medical recordkeeping. • Safe patient movement includes the
• In addition to performing technical skills, all following:
health professionals must be able to • Place the bed in a low position and
effectively communicate with each other lock its wheels.
and with their patients and patients' • Place all equipment (e.g. IV
families. equipment, nasogastric tube,
surgical drainage tubes) close to
Safety Considerations the patient to prevent
• Patient safety is always the first dislodgement during ambulation.
consideration in respiratory care. • Move the patient toward the
• Efforts must be made to minimize potential nearest side of the bed.
hazards associated with respiratory care. • Assist the patient to sit up in bed
• Key areas of potential risk are: (i.e., arm under nearest shoulder
• Patient movement and ambulation and one under farthest armpit).
• Electrical hazards • Place one hand under the patient's
• Fire hazards farthest knee and gradually rotate
the patient so that his or her legs are
a. Patient Movement and Ambulation dangling off the bed.
• Basic Body Mechanics • Let the patient remain in this
• Posture involves the relationship of position until dizziness or
the body parts to each other. lightheadedness lessens
• Good posture is needed to reduce (encouraging the patient to look
the risk of injury to the person lifting forward rather than at the floor may
patients or heavy equipment. help).
• Poor posture may place • Assist the patient to a standing
inappropriate stress on joints and position.
related muscles and tendons. • Encourage patient to breathe
easily and unhurriedly during this
• Moving the patient in bed initial change to a standing posture.
• Conscious people assume positions • Walk with patient using no, minimal,
that are most comfortable. or moderate support (moderate
• Bedridden patients with acute or support requires the assistance of
chronic respiratory dysfunction two practitioners, one on each side
often assume an upright position, of the patient).
with their arms flexed and their • Limit walking to 5 to 10 minutes for
thorax leaning forward. This position the first exercise.
helps decrease their work of • Monitor the patient during
breathing. ambulation.
• In other cases, patients may have to • Ask the patient about his or her
assume certain positions for comfort level frequently during the
therapeutic reasons such as when ambulation period.
postural drainage is applied. • Make sure that chairs are present so
emergency seats are available if
• Ambulation - helps maintain normal body the patient becomes distressed.
function. • Ambulation is gradually increased
until the patient is ready to be
discharged.
 • Each ambulation session is • Fires in oxygen-enriched atmospheres
documented in the patient chart (OEA's) are larger, more intense, faster
and includes the date and time of burning, and more difficult to extinguish.
ambulation, length of ambulation,
and degree of patient tolerance. • Hospital fires are also more serious
because evacuation of critically-ill patients
b. Electrical safety is difficult and slow.
• The potential for accidental shocks of
patients or personnel in the hospital exist For a fire to start, three conditions must exist:
due to the frequent use of electrical a. flammable material must be present
equipment. b. oxygen must be present
• The presence of invasive devices, such as c. the flammable material must be
internal catheters and pacemakers, may heated to or above its ignition
add to the risk of serious harm from temperature.
electrical shock. ▪ Fire is a real and serious hazard
• RT's must understand the fundamentals of around respiratory care patients using
electrical safety because respiratory care supplemental oxygen.
often involves the use of electrical devices. ▪ Flammable material should be
removed from the vicinity of oxygen
Types of electrical shocks: to minimize the fire hazards.
• Macroshock - exists when a high current ▪ Flammable materials include cotton,
(usually greater than 1 mA) is applied wool, polyester fabrics, and bed
externally to the skin. clothing, paper materials, plastics,
• Microshock - exists when a small, usually and certain lotions or salves such as
imperceptible current (less than 1 mA) petroleum jelly.
bypasses the skin and follows a direct, ▪ Ignition sources such as cigarette
low-resistance path into the body. lighters, should not be allowed in
• patients susceptible to microshock rooms where oxygen is in use.
hazards are termed electrically sensitive
or electrically susceptible. • The use of electrical equipment capable
of generating high energy sparks, such as
Preventing Shock Hazards exposed switches, must be avoided.
• Ground electrical equipment near the
patient. • All appliances that transmit house current
• all electrical equipment (e.g., lights, should be kept out of oxygen enclosures.
electrical beds, ventilators, monitoring
or therapeutic equipment) should be • Children should not play with toys that may
connected to the common grounded create a spark when oxygen is in use.
outlets with three-wire cords.
• RT's must be diligent in educating patients
• in these cases, the third (ground wire) and visitors about the dangers associated
prevents the dangerous build-up of with spark-producing items, open flames,
voltage that can occur on the metal and burning cigarettes in the hospital
frames of some electrical equipment. environment, especially in OEA's.

• all electrical equipment, particularly Core Fire Plan

those devices used with electrically • Rescue patients in the immediate area of
susceptible patients, must be checked the fire. the person discovering the fire
for appropriate grounding on a regular should perform the rescue.
basis by a qualified electrical expert.
c. Fire hazards • Alert other personnel to the fire so that they
• Hospital fires can be very serious, can assist in the rescue and can relay the
especially when they occur in patient care place of the fire to officials. This step also
areas and when supplemental oxygen is in involves pulling the fire alarm.
use.
• Contain the fire. After rescuing the
patients, shut doors to prevent the spread
 of the fire and the smoke. In patient care • RT’s need to become familiar with MRI-
areas, turn off oxygen zone valves. compatible ventilators, oxygen supplies,
and ancillary equipment.
• Evacuate other patients and personnel in
the areas around the fire who may be in MEDICAL GAS CYLINDERS
danger if the fire spreads. • The physical hazards resulting from
improper storage or handling cylinders
GENERAL SAFETY CONCERNS include:
• In addition to electrical and fire safety, RT’s • Increased risk of fire.
need to be aware of general safety • Explosive release of high-pressure
concerns, including: cylinders.
• Direct patient environment. • Toxic effect of some gases.
• Disaster preparedness. For numerous reasons, RT's are frequently a key
• Magnetic Resonance Imaging element to successful handling of hospital
Safety fires.
• Medical Gas Safety a. They know where the oxygen zone
valves are located and how to shut
DIRECT PATIENT ENVIRONMENT them off.
• Immediate environment around the b. They have the knowledge and skills
patient can create risk for patient safety. needed to evacuate patients
• To reduce the risk of patient falls and allow receiving mechanical ventilation or
easy access to care, the patient care supplemental oxygen to sustain life.
environment should be as free of c. They know how to treat and
impediments to care as possible. resuscitate victims of smoke
• It is the responsibility of the RT to position inhalation.
equipment, tubing, and treatments in a
way that does not impede access to care For these reason, RT's should be included in all
and that reduces risk of falls. hospital evacuation planning and
• When care is completed, the RT should practices.
ensure that the patient has easy access to
the patient call system. COMMUNICATION
• Communication - is a dynamic process
DISASTER PREPAREDNESS involving sharing of information, meanings,
• It involves learning to transport and transfer and rules among people.
critically-ill patients. • Communication has five basic
• Another component includes preparing components:
for a loss of electricity, whether it is due to a. Sender
an internal or external disaster. b. Message
• In these emergencies, hospitals have c. Channel
back-up generators to power essential d. Receiver
equipment. e. Feedback
• It is incumbent on the RT to know the
specific hospital policy for power failures • SENDER - is the individual or group
and other potential disasters. transmitting the message.

MAGNETIC RESONANCE IMAGING SAFETY • MESSAGE - the information or attitude

• MRI exposes the body to powerful communicated by the sender. May be (a)
magnetic fields and a small amount of verbal or (b) nonverbal. Verbal messages
radiofrequency. are voiced or written. Examples are
• This powerful magnetic field can create a lectures, letters, and e-mail memos. Non-
risk to patients, healthcare workers, and verbal communication is any
equipment of metal objects are brought communication that is not voiced nor
within specified proximity to the field. written. It includes gestures, facial
• Metal objects can be so forcefully expressions, eye movements and contact,
attracted to the magnetic field that they voice tone, space and touch.
can mimic a missile, causing physical
harm.
• CHANNEL - is the method used to transmit FACTORS INFLUENCING COMMUNICATION
messages. Most common channels are VERBAL EXPRESSIONS
those involving sight and hearing, such as • Language barrier
written and oral messages. • Jargon
• Choice of words/questions
• RECEIVER - is the target of the • Feedback, voice tone
communication and can be an individual •
or a group. One-on-one communication is NON-VERBAL EXPRESSIONS
often more effective because both parties • Body movement
can respond to each other. • Facial expressions
• Dress, professionalism
• FEEDBACK - from the receiver to allow the • Warmth, interest
sender to measure communication
success and provide additional ENVIRONMENTAL FACTORS
information when needed. • Lighting
• Noise
COMMUNICATION IN HEALTH CARE • Privacy
• As an RT, you will have many opportunities • Distance
to communicate with patients, other RT's, • Temperature
nurses, physicians, and other members of
the health care team. BASIC PURPOSE OF COMMUNICATION IN THE
• Poor communication skills can limit your HEALTH CARE SETTING
ability to treat your patients, work well with • To establish rapport with another
others, and find satisfaction in your individual, such as a colleague, a patient,
employment. or a member of the patient's family.
• RT's can communicate empathy to their • To comfort an anxious patient by
patients through the use of key words and explaining the unknown.
eye contact and the proper use of touch. • To obtain information, such as during a
• Communicating empathy to your patients patient interview.
is an effective way of letting them know • To relay pertinent information, as when
you truly care for their well-being and are charting the results of a patient's
willing to provide respiratory care that will treatment.
help their breathing. • To give instructions, as when teaching a
• Technique involves asking the patient patient how to perform a lung function
about his or her breathing on a regular test.
basis, and using gentle touch on the arm • To persuade others to take action, as when
or hand when comforting the patient. attempting to convince a patient to quit
smoking.
FACTORS INFLUENCING COMMUNICATION
INTERNAL FACTORS IMPROVING COMMUNICATION SKILLS
• Previous Experiences A. The practitioner as a Sender
• Attitudes, values a. Share information rather than telling.
• Cultural Heritage b. Seek to relate to people rather than
• Religious Beliefs control them.
• Self-concept c. Value disagreement as much as
• Listening Habits agreement.
• Preoccupation, feelings d. Use effective nonverbal
SENSORY communication techniques.
• Fear
• Anxiety, stress B. The practitioner as Receiver and Listener
• Pain a. Work at listening.
• Mental acuity, brain damage b. b. Stop talking.
• Sight, hearing, speech impairment c. c. Resist distractions.
d. d. Keep your mind open; be objective.
e. e. Hear the speaker out before making
an evaluation.
f. Maintain composure; control emotions.
 defensive when criticized, blocking clear
C. Providing Feedback communication.
a. Attending – uses gestures and
posture that communicates one’s CONFLICT AND CONFLICT RESOLUTION
attentiveness. It also uses confirming • Conflict - sharp disagreement or
remarks, such as, “I see what you opposition among people's interests,
mean.” ideas, or values.
b. Paraphrasing – repeating the other’s
response in one’s own words. • No two person are exactly alike in their
c. Requesting clarification – begins with background or attitudes, conflict can
an admission of misunderstanding be found in every organization.
on the part of the listener, with the
intent being to understand the • Health care professionals experience a
message better through restating or great deal of conflict in their jobs.
using alternative examples of
illustrations. • Rapid changes occurring in health
d. Perception checking – involves care have made everyone's jobs more
confirming or disproving the more complex and often more stressful.
subtle components of a
communication interaction, such as SOURCE OF CONFLICT
messages that are implied but not • Poor communication - If a supervisor is
stated. unwilling to accept different points of view
e. Reflecting feelings – involves the use for dealing with a difficult patient, an
of statements to determine better argument may occur. The importance of
the emotions of the other party. good communication cannot be
overemphasized.
MINIMIZING BARRIERS TO COMMUNICATION
1. Use of symbols or words that have different • Structural problems - Conflict tends to grow
meanings - Words and symbols (including as the size of an organization increases.
nonverbal communication) can mean Conflict is also greater in organizations
different things to different people. These whose employees are given less control
differences in meaning derive from over their work and in organizations where
differences in the background or culture certain individuals or groups have
between the sender and receiver and the excessive power. Structural sources of
context of the communication. conflict are the most rigid and are often
2. Different value systems - Everyone has his or difficult to control.
her own value system, and many people
do not recognize the values held by others. • Personal behavior - Different personalities,
3. Emphasis on status - A hierarchy of positions attitudes, and behavioral traits create the
and power exists in most health care possibility of great disagreement among
organizations. If superiority is emphasized health care professionals and between
by individuals of higher status, health care professionals and patients.
communication can be stifled.
4. Conflict of interest - If people are afraid that • Role conflict - is the experience of being
a decision will take away their advantage pulled in several directions by individuals
or invade their territory, they may try to who have different expectations of a
block communication. person’s job functions. A clinical supervisor
5. Lack of acceptance of differences in points is often expected to function both as a
of view, feelings, values or purposes - To staff member and as a student supervisor.
overcome this barrier, an effective Trying to fill both roles simultaneously can
communicator allows others to express cause stress and create interpersonal
their differences. conflict.
6. Feelings of personal insecurity. - It is difficult
for people to admit feelings of CONFLICT RESOLUTION
inadequacy. Individuals who are insecure A. Competing - Competing is an assertive and
do not offer information for fear that they uncooperative conflict resolution strategy.
appear ignorant, or they may be Competing is a power-oriented method of
 resolving conflict. A supervisor who uses generate their own standards of patient
rank or other forces to attempt to win is care.
using the competing strategy.
B. Accommodating - is unassertive and • For each standard, criteria must be
cooperative. When people outlined so that the adequacy of patient
accommodate others involved in conflict, care can be measured. Documentation
they neglect their own needs to meet the must reflect these standards.
needs of the other party.
C. Avoiding - Avoiding is both an unassertive PRACTICAL ASPECTS OF RECORDKEEPING
and an uncooperative conflict resolution • Recordkeeping is one of the most
strategy. In avoiding conflict, one or both significant duties that a health care
parties decide not to pursue their professional performs.
concerns. Avoidance may be appropriate • Documentation is required for each
if there is no possibility of meeting one’s medication, treatment, or procedure.
goals. • Accounts of the patient’s condition and
D. Collaborating - , the involved parties try to activities must be charted accurately and
find mutually satisfying solutions to their in clear terms.
conflict. Collaboration usually takes more • Accounts of care and the patient’s
time than other methods and cannot be condition are generally printed by hand or
applied when the involved parties harbor handwritten.
strong negative feelings about each other.
E. Compromising - People who compromise GENERAL RULES FOR MEDICAL
give up more than individuals who RECORDKEEPING
compete but give up less than individuals • Entries on the patient’s chart should be
who accommodate. Compromise is best printed or handwritten. After completing
used when a quick resolution is needed the account, sign the chart with one initial
that both parties can accept. and your last name and your title (CRT, RRT,
Resp Care Student; e.g., S. Smith, CRT).
RECORDKEEPING Institutional policy may require that
• Medical record or chart presents a written supervisory personnel countersign student
picture of occurrence and situations entries.
pertaining to a patient throughout his or
her stay in a health care institution. • Do not use ditto marks.

• Medical records are the property of the • Do not erase. Erasures provide reason for
institution and are strictly confidential. question if the chart is used later in a court
of law. If a mistake is made, a single line
• Medical record is a legal document. should be drawn through the mistake and
the word “error” printed above it. Then
• Because the law requires that a record be continue your charting in a normal
kept of the patient's care, a patient's chart manner.
is also a legal document. • Record after completing each task for the
patient, and sign your name correctly after
LEGAL ASPECTS OF RECORDKEEPING each entry.
• Hospital accreditation agencies critically
evaluate the medical records of the • Be exact in noting the time, effect, and
patient. results of all treatments and procedures.

• If the RT does not document care given • Chart patient complaints and general
(i.e., patient assessment data, behavior. Describe the type, location,
interventions, and evaluation of care onset, and duration of pain. Describe
rendered), the practitioner and the clearly and concisely the character and
hospital may be accused of patient amount of secretions.
neglect.
• Leave no blank lines in the charting. Draw
• Respiratory care departments, like all a line through the center of an empty line
departments in health care facilities, must
 or part of a line. This prevents charting by PROBLEM-ORIENTED MEDICAL RECORD (POMR)
someone else in an area signed by you. • POMR - an alternative documentation
• Use standard abbreviations. format used by some health care
institutions.
• Use the present tense. Never use the future • POMR contains four basic parts:
tense, as in “Patient to receive treatment a. Database - contains routine information
after lunch.” about the patient. A general health
history, physical examination results, and
• Spell correctly. If you are unsure about the results of diagnostic tests are included.
spelling of a word, look it up in a dictionary. b. Problem list - a problem is something that
interferes with a patient’s physical or
• Document conversations with the patient psychologic health or ability to function.
or other health care providers that you The patient’s problems are identified and
think are important (e.g., you informed the listed on the basis of the information
patient’s physician or nurse that the provided by the database. The list of
patient seems confused or more short of problems is dynamic; new problems are
breath) added as they develop, and problems
are removed as they are resolved.
GENERAL SECTIONS FOUND IN A PATIENT'S c. Plan
MEDICAL RECORD d. Progress notes - contain the findings
• Vital signs graphic sheet - records the (subjective and objective data),
patient's temperature, pulse, respirations assessment, plans, and orders of the
and blood pressure over time. physicians, nurses, and other
practitioners involved in the care of the
• I/O Sheet - records the patient's fluid intake patient. The format used is often referred
and output over time. to as SOAP (S = subjective information, O
= objective information, A = assessment,
• Laboratory Sheet - summarizes the results P = plan of care).
of laboratory tests.
SOAP NOTES
• Consultation Sheet - records notes by SOAP stands for Subjective, Objective,
physicians who are called in to examine a Assessment, Plan.
patient to make a diagnosis. • Subjective information obtained from the
patient, his or her family members, or a similar
• Surgical or Treatment Consent - records source
the patient's authorization for surgery or • Objective information based on caregivers’
treatment. observations of the patient, the physical
examination, or diagnostic or laboratory tests
• Anesthesia and Surgical Record - notes key such as arterial blood gases or pulmonary
events before, during, and immediately function tests
after surgery. • Assessment, which refers to the analysis of
the patient’s problem
• Specialized Therapy Records/Progress • Plan of action to be taken to resolve the
Notes - records specialized treatments or problem.
treatment plans and patient progress for
various specialized therapeutic services TO SUMMARIZE:
(e.g., respiratory care, physical therapy). • Good posture is needed when lifting
patients or heavy equipment to avoid
• Specialized Flow Sheets - records injury.
measurements made over time during • Begin patient ambulation as soon as a
specialized procedures (e.g., mechanical patient is physiologically stable and free of
ventilation, kidney dialysis). severe pain.
• Electrical current (flow) is the dangerous
element of electricity. Current is directly
related to voltage and inversely related to
resistance.
• A microshock is a small, imperceptible • Following accepted standards, each
current (< 1mA) that enters the body medication, treatment, or procedure
through external wires or catheters; provided to the patient, including his or her
microshocks can cause ventricular condition and response to therapy, must
fibrillation. be documented in accurate and clear
• To avoid electrical hazards, always ground terms.
equipment and use only equipment that • When entering notes in a POMR, use a
has been checked for proper wiring. SOAP format.
• Fires in health care facilities most often start
in the kitchen, but when they occur in
patient care areas, loss of life and serious
injuries are likely.
• Fire hazards can be minimized by
removing flammable materials and
ignition sources from areas where oxygen
is in use.
• RTs should be part of the hospital fire
evacuation team because they know
where oxygen shut-off valves are located,
they know how to move patients receiving
mechanical ventilation and oxygen
therapy, and they are trained at treating
smoke inhalation.
• Maintain a safe and clutter-free direct
patient care environment.
• Store and transport medical grade gases
in a safe and effective manner.
• Communication skills play a key role in the
ability to identify a patient’s problems, to
evaluate the patient’s progress, to make
recommendations for respiratory care,
and to achieve desired patient outcomes.
• Individuals’ prior experiences, attitudes,
values, cultural backgrounds, self-
concepts, and feelings play a large role in
the communication process.
• To enhance communication ability, focus
on improving sending, receiving, and
feedback skills; in addition, be able to
identify and overcome common barriers
to effective communication.
• One of five strategies can be used for
handling conflict: competing,
accommodating, avoiding, collaborating,
and compromising. Choosing the best
strategy requires knowledge of the
context, the specific underlying problem,
and the desires of the involved parties.
• The electronic medical record is
transforming the way we document care
but not the concept and content of what
is documented.
• A medical record is a confidential
document that summarizes the care
received by a patient; legally, a failure to
document care means that care was not
given.