Communication in Nursing: Documentation and Reporting

Communication is the cornerstone of nursing, building the nurse-client relationship and driving quality care. You manage every phase, from first contact through interventions to closing the therapeutic relationship. This covers the guidelines and phases of nursing communication, plus best practices for documentation, confidentiality, and overcoming barriers.

Communication in Nursing

Communication is the process of sharing information and generating meaning through mutually understood signs, symbols, and rules. It is the foundation of the helping-healing relationship and is essential for:

• Establishing therapeutic relationships, the primary way nurses connect with patients.
• Influencing behavior positively for better health outcomes.

Purpose of Communication

• Gathering information to make informed decisions.
• Validating information for accuracy and relevance.
• Sharing information, knowledge, and updates.
• Building relationships through trust and rapport.
• Expressing feelings.
• Imagining, sharing creative and conceptual thoughts.
• Influencing, guiding others toward ideas or actions.
• Meeting social expectations.

Elements of Communication

• Referent or stimulus: the motivation behind communicating, an objective, emotion, or need.
• Sender or encoder: the person who initiates the message.
• Message: the information, ideas, or feelings conveyed.
• Channel: the medium, auditory, visual, or tactile.
• Receiver or decoder: the person who interprets the message.
• Feedback: the response indicating whether the message was understood, completing the loop.

Steps in the Communication Process

1. Thinking: formulating the idea, such as deciding to explain antibiotics to a post-surgical patient.
2. Encoding: translating thoughts into words, text, or gestures the patient will understand, like simple language for an elderly patient.
3. Transmitting: sending the message through a channel (face-to-face, written note, digital), such as verbal instruction plus a written handout.
4. Perceiving: the patient receives the message through the senses, hearing the words and reading the handout.
5. Decoding: the patient interprets the message using their knowledge and cognition.
6. Understanding: the patient comprehends the intended message and can follow through, like knowing to complete the antibiotic course.

Channels of Communication

Auditory

• Hearing: perceiving sounds like conversations, alarms, or a call bell.
• Listening: actively interpreting spoken messages, such as a patient's symptom description.

Visual

• Sight: observing signs, body language, and visual aids, like a patient grimacing in pain.
• Reading: decoding written symbols such as charts and care plans.
• Observation: monitoring vital signs or behavior, like wound healing.
• Perception: awareness through the senses combined.

Kinesthetic

• Procedural touch: assessments and interventions, like locating a vein or palpating an abdomen.
• Caring touch: comfort and emotional support, like a reassuring hand on the shoulder.

Modes of Communication

Verbal Communication

1. Pace and intonation: how you speak shapes the message; speaking slowly and softly can calm an excited client.
2. Simplicity: use common words suited to the client's age, knowledge, culture, and education. Say "Tomorrow we need to get a sample of your urine by putting a small tube into your bladder" rather than "The nurses will be catheterizing you tomorrow for a urinalysis."
3. Clarity and brevity: say precisely what you mean in the fewest words, speaking slowly and enunciating.
4. Timing and relevance: time the message to the client's needs; an anxious client may not absorb unrelated explanations.
5. Adaptability: individualize what you say and how, shifting tone for a distressed client.
6. Credibility: be consistent, dependable, and honest, conveying confidence and acknowledging limits ("I don't know, but I will find someone who does").
7. Humor: a powerful tool, used carefully and according to the client's perception.

Nonverbal Communication

1. Personal appearance: dress and grooming reflect well-being; an acutely ill client asking for a shave or shampoo can signal improvement.
2. Posture and gait: erect posture and a purposeful stride suggest well-being; slouched posture and a shuffling gait may indicate depression or discomfort.
3. Facial expression: the most expressive part of the body; seek feedback when unclear and stay aware of your own expressions and eye contact.
4. Gestures: hand and body gestures emphasize or clarify words; a thumbs-up signals approval, crossed arms suggest defensiveness.

Electronic Communication

Many agencies use electronic medical records (EMRs) for assessments and care, improving efficiency, accuracy, and accessibility.

Email is fast, legible, and creates a record, but it poses confidentiality risks and is not suitable for urgent information, highly confidential details (HIV status, mental health, chemical dependency), or abnormal lab data. Agencies set standards to protect privacy and security.

Characteristics of Good Communication

1. Simplicity: common words, brief and complete. Say "We need to take a small amount of fluid from your back to check for an infection" rather than "We need to obtain a sample of cerebrospinal fluid via lumbar puncture."
2. Clarity: articulate exactly what you mean, speaking slowly. Say "Take one pill every morning with breakfast" rather than "Take this daily."
3. Timing and relevance: choose the right moment, ask one question at a time, and wait for a response.
4. Adaptability: adjust to the client's mood, like a gentler tone for a distressed patient.
5. Credibility: be trustworthy, accurate, and confident.

Factors Influencing Communication

1. Development: language and intellectual development vary across the lifespan; use simpler language and visual aids for a child.
2. Gender: communication styles can differ, some seeking confirmation and intimacy, others asserting independence and status.
3. Values and perception: a patient's cultural background shapes how they perceive suggestions like pain management.
4. Personal space: stand closer for emotional support (personal distance), step back for a public presentation (public distance).
5. Territoriality: respect the patient's space and belongings, asking permission before moving items.
6. Roles and relationships: word choice and tone vary by relationship, formal with an instructor, relaxed with peers.
7. Environment: noise, privacy, and comfort affect communication; choose a quiet, private room for sensitive topics.
8. Congruence: align verbal and nonverbal messages, conveying confidence while teaching colostomy care.
9. Interpersonal attitudes: caring, respect, and acceptance foster open, trusting communication, like listening without judgment to a patient's concerns.

Communicating with Clients Who Have Special Needs

Clients Who Cannot Speak Clearly (Aphasia, Dysarthria, Muteness)

• Listen attentively, be patient, and do not interrupt.
• Ask simple yes-or-no questions.
• Allow time for understanding and response.
• Use visual cues: words, pictures, objects.
• Allow only one person to speak at a time.
• Do not shout; keep a calm tone.
• Use communication aids: pad and pen, magic slate, pictures of basic needs, call bells.

Clients Who Are Cognitively Impaired

• Reduce environmental distractions.
• Get the client's attention before speaking.
• Use simple sentences and avoid long explanations.
• Ask one question at a time and wait.
• Be an attentive listener.
• Include family and friends, especially on familiar subjects.

Clients Who Are Unresponsive

• Call the client by name.
• Communicate verbally and by touch.
• Explain all procedures and sensations.
• Provide orientation to person, place, and time.
• Avoid talking about the client to others in their presence.
• Avoid saying things the client should not hear.

Clients with Hearing Impairments

• Establish a method (pen and paper or sign language).
• Attend to non-verbal cues.
• Decrease background noise.
• Always face the client to allow lip-reading.
• Consult family on the best methods.
• Contact resources for communication aids.

Clients Who Do Not Speak English

• Speak in a normal tone; shouting reads as anger.
• Establish a signal for the client to request communication (call light or bell).
• Provide an interpreter.
• Avoid using family, especially children, as interpreters.
• Develop communication boards, pictures, or cards.
• Have a dictionary available if the client can read in their language.

Barriers to Effective Communication

• Giving an opinion, which takes decision-making from the client and stalls problem-solving.
• Offering false reassurance, twisting the truth into something vague.
• Being defensive, harmful to both parties.
• Showing approval or disapproval, which implies the praised behavior is the only acceptable one.
• Stereotyping, which threatens the relationship.
• Changing the subject inappropriately, which shows a lack of empathy.
• Language barrier, when communicators cannot understand each other.
• Time barrier, approaching someone at the wrong moment.
• Lack of knowledge on the topic, which complicates the exchange.
• Information overload, which outpaces the listener's processing and breaks down communication.

Phases of Communication

Orientation Phase

The tone and guidelines are established. Despite being strangers, each brings preconceptions. Define the parameters: place, length, frequency, roles, confidentiality, and duration. Trust, respect, honesty, and communication are foundational. For example, the nurse explains the purpose of a hospital stay, outlines daily routines, and ensures the patient knows their rights.

Working Phase

The longest phase, where most interventions happen. Problems are identified and plans put into action, with positive change alternating with resistance. The nurse validates the client's thoughts, feelings, and behaviors and helps them explore their views and feelings (grief, anger, mistrust) and behaviors (aggression, withdrawal). The client chooses the content; the nurse facilitates and continues assessment, advocating for the client's priorities. For example, helping a patient with diabetes set diet and exercise goals, monitor blood sugar, and learn insulin administration.

Termination Phase

The final stage, when the agreement's conclusion is acknowledged. After addressing the client's problems, the relationship is completed and ended on mutual understanding, celebrating goals met. Loss can accompany the ending, so sharing feelings and validating future plans helps. For example, reviewing progress, confirming the patient can manage independently, and providing follow-up plans before discharge.

Reports in Healthcare

Reports exchange information among caregivers for continuity and quality. They can be oral, written, or audio-recorded:

• Change-of-shift report: a comprehensive update at shift changes covering status, treatment plans, and significant events.
• Telephone report: information by phone for updates or consultations across locations.
• Telephone or verbal orders: only registered nurses (RNs) are authorized to accept these; document immediately.
• Transfer report: the patient's condition, recent treatments, and instructions when moving departments or facilities.
• Incident report: documentation of unusual or adverse events (falls, medication errors) to improve safety.

Documentation in Nursing

Documentation is any written or printed material relied on as a record for authorized personnel. It is vital to nursing practice, and effective documentation is accurate, comprehensive, and flexible.

Accuracy means precise, exact recording, which is crucial for clinical decisions. Comprehensiveness means including all necessary details, from history and current condition to treatments and responses. Flexibility lets professionals retrieve data, maintain continuity, track outcomes, and reflect current practice standards.

Good documentation ensures continuity, saves time, and minimizes errors. It prevents fragmented care, reduces repetition, and avoids delays or omissions.

Confidentiality

Confidentiality is a cornerstone, rooted in legal and ethical obligations. Handle all data with confidentiality and ensure only authorized personnel have access:

• Legal and ethical obligation: law and ethics require keeping client information confidential.
• Restricted information sharing: do not discuss a client's care with anyone not directly involved.
• Access to records: only staff directly involved in care have legitimate access.
• Client rights: clients may request and read copies of their records.
• Protection of records: safeguard physical and electronic records from unauthorized access.
• Authorized use: obtain authorization for data gathering, research, or education per policy.
• Professional behavior: protect sensitive information diligently.
• Prohibition of gossip: sharing personal information violates ethical codes and damages trust.

Guidelines for Quality Documentation and Reporting

• Factual: record objective observations through sight, hearing, touch, and smell, avoiding vague terms like "appears" or "seems." Instead of "The client seems anxious," document "The client is wringing their hands, has a furrowed brow, and is breathing rapidly at 22 breaths per minute."
• Accurate: use exact measurements. Document "Client's temperature is 101.4°F (38.6°C)" rather than "Client has a fever."
• Complete: include all relevant information. For example, "The client verbalizes sharp, throbbing pain localized along the lateral side of the right ankle, beginning approximately 15 minutes ago after twisting their foot on the stair. Client rates pain as 8 on a scale of 0-10. Administered 500 mg of acetaminophen orally. Client reports pain reduced to 4 on a scale of 0-10 after 30 minutes."
• Current: record promptly. For example, "Administered 2 mg morphine IV at 14:00 for pain rated at 7/10. Client reports pain relief to 3/10 by 14:30."
• Organized: present information logically, condition then assessment then intervention then response. For example, "Client reports sharp, constant abdominal pain at 8/10. Assessed abdomen, noted rigidity and rebound tenderness in the right lower quadrant. Informed physician, who ordered an abdominal CT scan. Administered 4 mg ondansetron IV for nausea. Client reports pain reduced to 5/10 after 30 minutes, and nausea subsided."

Legal Guidelines for Recording

• Correcting errors: draw a single line through the error, write "error" above it, and sign or initial, then record the correct information. If you document a heart rate as 80 bpm when it is 90 bpm, line through "80," write "error," initial, and write "90 bpm."
• Professional language: avoid retaliatory or critical comments. Instead of "The doctor was rude and unhelpful," write "Discussed treatment options with Dr. Smith."
• Objective descriptions: enter only objective behavior, quoting the client's exact words. Write "Client stated, 'I feel dizzy and can't keep my balance,'" rather than "Client seems unsteady."
• Prompt corrections: correct errors immediately. For example, "Administered 5 mg morphine at 1400 hrs, not 50 mg."
• Accurate charting: do not rush; document vital signs, medications, and responses thoroughly.
• No blank spaces: chart line by line. If space is left, draw a line through it and sign, to prevent tampering.
• Legible entries: record legibly in black ink, never pencil or felt pen, since black ink photocopies and microfilms best. This may vary by agency.
• Clarification of orders: document that clarification was sought. For example, "Clarified with Dr. Jones regarding the dosage of insulin; confirmed to administer 10 units instead of 100 units."
• Accountability: chart only for yourself. For example, "Wound dressing changed by J. Smith, RN."
• Specific descriptions: avoid empty phrases like "status unchanged" or "had a good day." Instead, "Client ambulated 50 feet with minimal assistance, reported pain level of 2/10."
• Timeliness: begin each entry with the time and end with your signature and title; do not wait until the end of the shift. For example, "1300 hrs: Administered 500 mg acetaminophen for headache. J. Smith, RN."
• Computer documentation: keep your password secure, never share it, and do not leave the screen unattended once logged in. Log out of the electronic health record before stepping away.