Professional communication 1

Professional communication 1 (Lesson 7)

Interacting with patients
Lesson objectives:
In this lesson, you will learn:

- how to conduct a medical interview

- language for patient care
- how to break bad news and deal with sensitive issues
- appropriate body language
- the structure, tone and language features of brief narrative notes
- to practise writing brief narrative notes accurately

A. Healthcare Professional-Patient Communication

1. Conducting a medical interview

A chief responsibility of nurses is to develop a nursing care plan for every one of their patients that
appropriately identifies his/her health problems, outlines care goals and expected outcomes, and
specifies nursing interventions. To assess a patient’s state of health and individual needs, nurses have to
obtain information from the patient through comprehensive interviewing; the data gathered are then
analyzed to determine a focused, patient-centered care plan.

Steps in patient-centered interviewing

1.1 Setting the stage for the interview

• Welcome the patient.
• Introduce yourself and identify your role.

Useful phrases:
Good morning, Mr. Lee, I’m Alex, a registered nurse here at the clinic.
Hi, Ron. I’m Dr. Murray. I’ll be looking after you during your stay at the hospital

Activity 1

With a partner, read extract 1 taken from a medical interview between a doctor and a patient. One of you read
the lines as a doctor and the other as a patient. Then answer the questions that follow.

Extract 1:
Doctor: Ms. Joanne Jones? Welcome to the clinic. I’m Michael White, the medical student who will
be working with you along with Dr. Black. How would you like me to address you?
Patient: Mrs. Jones is fine.

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Doctor: Okay Mrs. Jones, I’ll be getting much of the information about you and will be in close
contact with you about our findings and your subsequent care.
Patient: I wasn’t sure who I was going to see. This is my first time here.
Doctor: If it’s OK with you, I’ll close this door so we can hear each other better and have some
privacy.
Patient: Sure, that’s fine.
Doctor: Anything I can help with before we get started?
Patient: Well, they didn’t give my registration card back to me. I don’t want to lose it.
Doctor: We’ll give that back when we’re finished today. They always keep them. Is there something
else?
Patient: No.
Doctor: Would you like to sit in that chair? It’s more comfortable than the examining table.
Patient: Sure. Thanks.
Doctor: Well, I’m glad to see you made it despite the snow. I thought spring was here last week.
Patient: I guess not. My kids have been home the last 2 days. I’m ready to get them back to school!
I’m getting spoiled with them both in school.
Doctor: People have had all kinds of trouble getting in here for their appointments since the snow.
It’s no fun.
Patient: You’re telling me. I don’t even ski!

1. What does the doctor do to set the stage for the interview to go smoothly?

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

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1.2 Eliciting the patient’s chief concern

• Explain what will be done in the interview.
• Obtain a list of issues the patient wants to discuss.
• Summarize the information gathered.

Useful phrases:
I’ll ask you some questions before Dr. Jenkins sees you.
I’d like to start by asking some questions about your health concerns if that’s okay with you.
What seems to be the problem?
What brings you here today?
Perhaps we can start by getting a list of the things you’d like to address today.
Before we look at this in detail, could you tell me if there are other issues you want to discuss today so we
can cover everything?
What other concerns do you have?
Is there anything else besides this?

Activity 2

With a partner, read extract 2 taken from a medical interview between a doctor and a patient. One of you read
the lines as a Doctor and the other as a Patient. Then answer the questions that follow.

Extract 2:
Doctor: Well, we’ve got about 40 minutes today and I know I’ve got a lot of questions to ask
and that we need to do a physical exam. Before we get started, though, I like to get a
list of the things you wanted to address today. You know, so we’re sure everything gets
covered.
Patient: It’s these headaches. They start behind my eye and then I get sick to my stomach so I
can’t even work. My boss is really getting upset with me. He thinks that I don’t have
anything wrong with me and says he’s going to report me. Well, he’s not really my
boss, but rather is ...
Doctor: That sounds difficult and really important. Before we get into the details, though, I’d
like to find out if there are some other problems you’d like to look at today, so we can
be certain to cover everything you want to. We’ll get back to the headache and your
boss after that. Your headache and your boss—that’s two things. Is there something
else you wanted to address today?
Patient: Well, I wanted to find out about this cold that doesn’t seem to go away. I’ve been
coughing for 3 weeks.
Doctor: OK, cough; what other concerns do you have?
Patient: Well, I did want to find out if I need any medicine for my colitis. That’s doing ok now
but I’ve had real trouble in the past. It started bothering me back in 1999 and I’ve had
trouble off and on. I used to take cortisone and ...
Doctor: So, there are two more problems we can look into, the colitis and the medications.
We’ll get back to all these soon; they’re all important. To make sure we get all your
questions covered, though, is there something else?
Patient: No. The headache is the main thing.

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2. What does the doctor do to get the patient to list all her concerns before moving on to the details without
sounding impatient?

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

3. Before going into the details of the patient’s concerns, the doctor should summarize the information
gathered thus far and check its accuracy. Complete the script above with a brief summarizing statement to
conclude this part of the conversation.

1.3 Obtaining the history of present illness

• Ask non-focusing open-ended questions to allow the patient to express his/her concerns.
• Ask focusing open-ended questions to obtain specific details.
• Use attentive listening and show empathy to encourage communication.
• Gather additional information from non-verbal cues from the patient.

Useful phrases:
Tell me about your headache.
Can you tell me more about the chest pain?
How long have you had this for?
How long does the spasm last?
Could you show me where it hurts?
Does it spread anywhere?
Did the numbness start suddenly or gradually, say, over a few days/ weeks?
Have you noticed anything that brings it on?
What makes it better? What makes it worse?

Activity 3

With a partner, read extract 3 taken from a medical interview between a doctor and a patient. One of you read
the lines as a Doctor and the other as a Patient. Then answer the questions that follow.

Extract 3:
Doctor: So, tell me all about the headache.
Patient: It’s not bad at the moment, I guess.
Doctor: Uh Huh.
Patient: Things weren’t so good last week, though, when I made the appointment.
Doctor: Mmmm.

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Patient: That’s when my boss really got on me. Well, he’s kind of uptight anyway, but he was
saying how I was upsetting the whole office operation because I was off so much. And
someone had to cover for me. I’m the lead attorney.
Doctor: I see.
Patient: They’re right here and just throb and throb. And I get sick to my stomach and just don’t
feel good. All I want to do is go home and go to bed.

4. Why does the doctor start his enquiry with an open-ended question?

__________________________________________________________________________________

5. Doctors often don’t say too much at this stage of the interview. What can they do instead to demonstrate
their participation?

__________________________________________________________________________________

__________________________________________________________________________________

1.4 Summarizing the information gathered

• Briefly summarize what you have learned from the patient.

• Use repetitions and close-ended questions to check accuracy.

Useful phrases:
So, you said the pain is dull? It started as a numbness, and then turned into a sharp pain over the week.
Right… the panic attacks usually came on when you had to wrap up a project at work. And the symptoms
you experienced were similar: chest tightness, nausea and dizziness. Did the symptoms persist after the
projects were finished?

Activity 4

With a partner, read extract 4 taken from a medical interview between a doctor and a patient. One of you read
the lines as a Doctor and the other as a Patient. Then answer the questions that follow.

Extract 4.1:
Doctor: Say more about the headaches.
Patient: Well, I never had any trouble until I started working there.
Doctor: How long’s that been?
Patient: Only 4 months. The headache started about 3 months ago.
Doctor: Tell me more.
Patient: Well, they just throb and throb and it seems like every time I see my boss I get one of
these headaches. I sometimes just get a little nauseated and can’t concentrate
because of the pain.
Doctor: Nauseated?

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Patient: Yeah, queasy like I might throw up, but I never have.
Doctor: What more can you tell me about the headaches or nausea?
Patient: That’s all I can think of.

6. Circle the open-ended questions or requests AND underline the close-ended ones.

7. What does the doctor learn about the patient’s headaches through his questioning technique?

__________________________________________________________________________________

__________________________________________________________________________________

Open Vs Closed Questions

With a partner, read extract 4.2 and 4.3 taken from a medical interview between a doctor and a patient.
One of you read the lines as a Doctor and the other as a Patient. Then answer the questions that follow.

Extract 4.2
Doctor: Now about this chest pain – where is the pain?
Patient: Well, over the front here (Pointing to the sternum)
Doctor: What are the pains like- are they a dull ache or a sharp pain?
Patient: Quite sharp, really.
Doctor: Have you taken anything for it?
Patient: Just some antacids, but they don’t seem to help much
Doctor: Do the pains go anywhere else?
Patient: No, just there.

Source from which the script used above was adapted:

Silverman, J., Kurtz, S., & Draper, J. (2016). Skills for Communicating with Patients, 3rd Edition. London: Chapman
and Hall/CRC.

A more open-ended questioning style might reveal very different information:

Extract 4.3
Doctor: Tell me about the chest pain that you have been having
Patient: Well, it’s been building up over the last few weeks. I’ve always had a little indigestion,
but not as bad as this. I get this sharp pain right here (pointing to sternum) and then I
belch a lot and get a horrible acid taste in my mouth. It’s much worse of I’ve had a
drink or two and I’m not getting much sleep.
Doctor: I see. Can you tell me more about it?
Patient: Well, I was wondering if it was brought on by the tablets I’ve been taking for my joints
Doctor: they’ve been much worse and I took some ibuprofen. I need to keep going at the
Patient: moment, what with John and all.

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Source from which the script used above was adapted:

Silverman, J., Kurtz, S., & Draper, J. (2016). Skills for Communicating with Patients, 3rd Edition. London: Chapman
and Hall/CRC.

8. What are some advantages of open questioning techniques?

• _____________________________________________________________________
• _____________________________________________________________________
• _____________________________________________________________________
• _____________________________________________________________________
• _____________________________________________________________________

1.5 Obtaining further information pertaining to the patient’s chief concern

• Ask close-ended questions to elicit information about the patient’s past medical history, family history,
and personal and social circumstances.

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Useful phrases:
Do you have any other medical problems?
Have you had any illnesses in the past?
Have you been operated on in the last 5 years?
Are there any medical problems that run in the family?
Are you aware of any close relatives with similar health problems?
Are you taking any medications?
Are you allergic to any medications?
How often do you consume alcohol?
Do you smoke anything?
How would you describe your activity level—active, moderately active or sedentary?
Do you talk with anyone about the problems you’ve been experiencing?

Activity 5

With a partner, read extract 5 taken from a medical interview between a doctor and a patient. One of you
read the lines as a doctor and the other as a patient. Then answer the questions that follow.

Extract 5:
Doctor: So, you’re in a new job that hasn’t worked out quite like you were led to believe and
that has caused you some upset with at least a couple people and quite bad
headaches. Do you want to add anything?
Patient: No. I think you’ve pretty much got it.

9. After gathering some details about the patient’s first concern, the doctor is going to discuss with the
patient her second concern. Write an appropriate sentence for switching the topic from headaches
to colitis.

__________________________________________________________________________________

__________________________________________________________________________________

Source from which the extracts used in this activity were adapted: Fortin, A. H., Dwamena, F. C., Frankel, R. M., & Smith, R. C.
(2012). Smith’s patient centered interviewing: An evidence-based method (3rd ed., pp. 29-62). New York, NY: McGraw Hill.

2. Admitting patients

After a patient’s need for admission to an in-patient setting is identified, staff in the receiving unit or
facility will begin the admission process. On admission, the staff collects personal information from the
patient for identification purposes, and health information for an initial assessment and care planning.
They also inform the patient of relevant hospital policies and any treatment or medical procedure he/she
will receive.

Patient admission process

1. Greet the patient and introduce yourself.

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2. Check the patient’s identity bracelet to ensure all information is correct.

3. Assist the patient into the provided hospital gown, if necessary.
4. Take the patient’s weight and height measurements.
5. Transfer the patient to his/her bed.
6. Explain the use of ward equipment such as the nurse call.
7. Orientate the patient to the ward and hospital’s layout and facilities such as washrooms and water
coolers.
8. Inform the patient about the hospital’s routine such as meal times and visiting hours.
9. Record the patient’s arrival date and time, and reason for the admission, in the patient care record.
10. Measure the patient’s vital signs.
11. Verify if the patient has any drug or food allergies.
12. Conduct an initial patient assessment and develop a care plan.
13. Give the patient information about any treatment, screening test or medical procedure he/she will
receive, and answer any question they may have.

The following is a sample conversation between a nurse and a patient on admission. Note how the nurse
gives and elicits information.

Nurse: Good morning, Mrs. Chad. My name’s Shona. I’ll be admitting you to the ward today.
Would you like to come into the Patient Admission Office so I can get some paperwork
done?
Patient: Good morning, Shona. Yes, thanks. I could do with a sit-down.
Nurse: Here you are. You take this chair here. You can put the stick on the edge of the chair if
you like.
Patient: Thank you, dear.
Nurse: How are you today?
Patient: Not too bad, thank you. I haven’t been waiting for too long at all.
Nurse: That’s good. Now, I’m going to be taking down some details before you’re admitted
to the Cardiac Unit today. I’d like to ask you a few questions, if it’s all right with you?
Patient: Yes, of course. That’s fine.
Nurse: All right. Well now, let me just get the Admission Form… Right, let’s get started. Would
you mind if I check out some details first?
Patient: No, not at all. What would you like to know?
Nurse: I’d just like to check your name and date of birth, and see if your identity bracelet is
correct. Can you tell me your full name, please?
Patient: Yes, it’s Doreen Mary Chad.
Nurse: Mm-hmm.
Patient: And my date of birth is the fifth of June, 1923. Quite a while ago, isn’t it?
Nurse: Not so long ago. Time goes fast when you’re busy, doesn’t it? Right, now… let’s see,
Doreen Mary Chad.
Patient: Mm-hmm.
Nurse: C-H-A-D. That’s correct, isn’t it?
Patient: Yes, that’s right. Chad with a D.
Nurse: And your date of birth is the fifth of June, 1923.
Patient: Yes.
Nurse: All right. Can you tell me why you’re here today?
Patient:

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Well, I’ve got high blood pressure, and I’m here for some tests. My doctor asked me to
Nurse: come here to see what’s going on.
OK. Now, I’d like to ask you about your past medical history. Have you had any serious
Patient: illnesses in the past?
Nurse: Yes, I had a mild heart attack last year. It was quite frightening.
Yes, I’m sure it was. Now, er, what about past surgical history? Have you ever had any
Patient: operations?
Nurse: No, I’m very lucky. I never have.
Patient: That is lucky. Now, are you taking any medications at the moment?
Nurse: Yes. My doctor put me on some blood pressure tablets after my heart attack.
Patient: Mm-hmm. Do you know what they are called?
Nurse: I don’t know but I’ve got them here with me. I was told to bring them.
Patient: That’s good. Do you think you can show them to me, please?
Yes, I can. I’ve got them somewhere in my bag… Ah, here they are. I take them in the
Nurse: morning with breakfast.
Patient: Right, that’s fine. You’re taking metoprolol to lower your blood pressure.
Nurse: Oh.
I’ll just write down the name of the medication on the Admission Form… metoprolol.
Patient: Do you have any allergies to any medications?
Nurse: Not that I know of.
Patient: Erm, what about food allergies? Any food which doesn’t agree with you?
Nurse: No, no. Nothing like that.
Patient: Good. Are you allergic to sticking plaster or iodine?
Nurse: No, I’ve never had problem before.
Patient: All right. Can you tell me the name of your next of kin?
Nurse: It’s my son, Jeremy. Jeremy Chad.
Thanks. That’s all for me. I’ll leave you here for a minute while I get the attending
Patient: doctor to come and see you. Are you comfortable?
Yes, thanks. I’m quite all right here.
Source from which the script used above was adapted:
Allum, V., & McGarr, P. (2008). Cambridge English for nursing: Intermediate plus. Dubai, UAE:
Cambridge University Press.

To request action/ elicit information politely:

• Would you like to…?
• Would you mind if I…?
• Can you…, please?

To indicate action or intention:

• I’ll be…
• I’m going to…
• I’d like to…

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3. Discharging and transferring patients

When a patient’s episode of care within an in-patient setting is concluded, he/she may be discharged or
transferred to another in-patient facility such as a hospice or rehabilitation center. To ensure the patient’s
self-management at home or continuation of care at the receiving facility, the discharge plan should be
individually-based and take into account the patient’s specific needs; post-hospital care instructions to
the patient or the receiving facility should be thorough. The patient should be fully engaged in the
discharge planning.

Patient discharge process

1. Evaluate the patient’s progress to determine if he/she should be released.
2. Discuss the discharge planning with the patient.
3. Make arrangements (e.g. transportation) for homecoming or transfer to another care facility.
4. Arrange for follow-up appointments or tests.
5. Review with the patient his/her discharge instructions.
6. Explain to the patient his/her prescriptions and ensure he/she knows when and how to take the
medications.
7. Inform the patient about any equipment or supplies necessary for home care.
8. Give the patient advice on physical activities and diet, if applicable.
9. Check if the patient has any concerns or questions.

The following is a sample conversation between a nurse and a patient about his self-management after
discharge from the hospital. Note the strategies the nurse uses to get her message across.

Nurse: Hello, Mr. Hockings. I wonder if I can have a chat with you about your blood pressure
management before you go home.
Patient: Hello, Susanna. Yes, sure.
Nurse: Great, I’ll just grab a chair. Now, you’ve a bit of a shock with your blood pressure,
haven’t you.
Patient: Yes. You’re right there. I mean, I have no idea. I was feeling more tired than usual and
then my wife said she noticed my face was a bit flushed. But the thing is I never thought
about blood pressure.
Nurse: Hmm… yeah, that’s probably why they call it the ‘silent killer’. For most people, the
only symptom they have of hypertension is high blood pressure itself.
Patient: Well, like you said, it was a bit of a shock. So, what do I have to do when I go home?
What should I watch for?
Nurse: Well, now, remember that yesterday we went through all these lifestyle changes I got
you to look at?
Patient: Yes. I got all the information about the Stop Smoking Service. I started on the nicotine
patches. The dietitian spoke to me yesterday about healthier diet. My wife even went
out and bought a cookbook. We’ll both start the exercise program here at the hospital.
Nurse: I can see you cooking up a storm in the kitchen.
Patient: I don’t know about that. I don’t think my wife will agree with you.
Nurse: You did well to remember all the information. It’s a lot to take in at once and I’m really
pleased you’re fired up and ready to go. The only other thing we need to talk about is
your blood pressure itself. It would be a good idea to buy a small blood pressure

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monitor and take your blood pressure regularly. That way you can keep an eye on it
Patient: yourself. It puts you in charge of your own health. I think that’s important, don’t you?
Yeah, you’re right. It’s much better that way.
Source from which the script used above was adapted:
Allum, V., & McGarr, P. (2008). Cambridge English for nursing: Intermediate plus. Dubai, UAE:
Cambridge University Press.

4. Language for Patient Care

4.1 Consultations should follow the following pattern:

• Introduction / small talk
• Complaint
• History of present condition
• Past medical history
• Family / social / recent history

4.2 Communicative functions to perform in consultations:

• Indicate the purpose of the conversation.
• Engage the patient, allowing him/her to express his/her thoughts and feelings.
• Stress the importance for the patient to take action to manage his/her condition.
• Check the patient’s understanding of the information given.
• Show understanding to the patient of the effort his/she will have to make to undertake major lifestyle
changes.
• Offer support and encouragement.

4.3 Introduction / Small talk:

• Put patients at ease
• Let them know your open / friendly
– How do you like this weather?
– Are you busy these days?
• If you have seen the patient before, ask them if they got better

4.4 Asking about the patient’s complaint / reason for visit

• Use safe common phrases
– How can I help you today?
– What seems to be the problem?
– What brings you here today?
• Elicit further information
– Is there anything else?

4.5 Asking about history of present condition / Past medical history

• Use simple, everyday English

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– How long
– When did
• Useful words and expressions
– notice
– become aware of
– been bothering you
– feeling this way

4.6 Tone and Register

• Use simple, everyday English.
• Use plain language.
• Use a friendly, professional tone.
• Do not sound formal or too casual.
• Talking too formally can sound scary in English.

5. Breaking bad news and dealing with sensitive issues - Listening Practice
Breaking bad news is the one communication issue that most healthcare professionals find challenging.
However, you can deal with sensitive issues by using more appropriate language and softening the tone.

5.1 Dealing with sensitive issues

Listen to the conversation and circle the most appropriate dialogue

1. A B

2. A B

3. A B

4. A B

6. Facilitating further response

What other skills might facilitate further response?

• _____________________________________________________________________

• _____________________________________________________________________

• _____________________________________________________________________

• _____________________________________________________________________

• _____________________________________________________________________

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Nurse: Tell me about the chest pain that you have been having (open question)
Patient: Well it’s been building up over the last few weeks. I’ve always had a little indigestion
but not as bad as this. I get this sharp pain right here (pointing to sternum) and then I
belch a lot and get a really horrible acid taste in my mouth. It’s much worse if I’ve had
a drink or two, and I’m not getting much sleep.
Nurse: Yes, go on (encouragement)
Patient: Well, I was wondering if it was brought on by the tablets I’ve been taking for my joints-
they’ve been much worse and I got some ibuprofen from the chemist. I need to keep
going at the moment, what with John and all.
Nurse: (silence- accompanied by eye-contact, slight head nod)
Patient: He’s really going downhill, doctor and I don’t know how I’m going to cope at home if
he gets any worse.
Nurse: How you’re going to cope? (repetition)
Patient: I promised him I wouldn’t let him go into hospital again, and now I’m not sure if I can
do it .

Source from which the script used above was adapted:

Silverman, J., Kurtz, S., & Draper, J. (2016). Skills for Communicating with Patients, 3rd Edition. London: Chapman
and Hall/CRC.

B. Non-verbal Communication Skills

Non-verbal communication is often described as body language. The way we position our body says a lot
about our engagement and interest in communication. Even if we are verbally communicating the right
way the actual message we are communicating to our patients may be lost because our body language
may suggest we’re thinking something else.

1. Watch a video on non-verbal communication and answer the following questions:

https://www.youtube.com/watch?v=C8OB0p85D1E

1.1 What does non-verbal communication include?

1.2 Which of the following techniques are recommended for efficient non-verbal communication? Tick
the correct ones.

Facing the person 

Listening passively 
Maintaining eye contact 
An open stance 
Frequent nodding 
Standing over a person 
Talking to a person at eye level 
Leaning forward 
Smiling 

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2. Watch another video and answer the following questions:

https://www.youtube.com/watch?v=vpPX70V_zIY

2.1 The tone and pitch of the voice, as well as the speed, pace, volume and inflection of the

conversation are aspects of __________________________________.

2.2 What may hesitation be interpreted as?

2.3 When the perceived verbal and non-verbal messages do not match, which of the two would likely be
considered by the receiver to be true?

2.4 What does body language include?

2.5 What do the common gestures we use include?

2.6 What type of body language conveys most of the non-verbal messages?

2.7 Facial expressions include

Before carrying on with the video, can you guess the answers to the following?

2.8 What does a child do before crying?

2.9 What may raising eyebrow indicate?

2.10 What does rapid blinking mean?

2.11 If a person leans backwards with arms crossed, what does that indicate?

2.12 An erect posture indicates

2.13 A slouched posture can indicate

2.14 People from what cultures may consider sustained eye contact to be disrespectful?

2.15 ________________ may be used to communicate comfort, compassion and caring but may be
considered a violation of person space for some people?

2.16 What other type of non-verbal communication may also reveal the person’s cultural and religious
beliefs?

2.17 Why may a nurse in a pediatric setting avoid wearing white uniforms?

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3. Compare the following two scenarios

With a partner, discuss the differences between the two consultations between a doctor and a patient.
They are discussing the same issue but the message conveyed by the doctor is very different.

Take notes on the following:

• Body language
• Facial expression
• Language use

Video 1:https://www.youtube.com/watch?v=-JSxDoNzy0g

Video 2: https://www.youtube.com/watch?v=-1Ba9juSMfM

Activity 2

In pairs, role-play a conversation between a hospital ward nurse and a patient.

Student A
ROLE-PLAY 1
You are a hospital ward nurse. A new patient has just been admitted to your ward. You are about to greet
the patient and check the information on his/her identify bracelets. Ask suitable questions to obtain the
information.

What you will have to check:

• the patient’s full name
• his/her date of birth
• whether he/she has any allergy
• whether his/her additional bracelet is of the right color
o red for allergy
o orange for infection risk
o green for fistula
o blue for cognitive impairment

After completing some paperwork at the nurse station, you are with your patient again. Fill out the Patient
Admission Form by asking the patient relevant questions.

Patient Admission Form

Family name:
Given name(s):
DOB:

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Ward: 12-F
Physician: Dr. Raymond C. Yan

Date of admission: 25.07.2017

Reason for admission:
Past medical history:
Past surgical history:
Current medications:
Allergies:
Next of kin:

ROLE-PLAY 2
You are a patient who has just been admitted to a hospital. The ward nurse is about to ask you some
questions to verify your identity. Answer his/her questions with the following information.

• Name: Wing-man Lam

• DOB: 30/12/1970
• Allergy: penicillin

The nurse has come back to ask a few additional questions. Answer his/her questions using the following
information.

• Reason for admission: food poisoning (sent to ward by A&E)

• Past illness: Lyme disease (last year)
• Past operation: gastric bypass (5 years ago)
• Current medication: potassium chloride for low potassium levels (started 3 years ago)
• Next of kin: Chandler Wong (cousin)

Student B

ROLE-PLAY 1
You are a patient who has just been admitted to a hospital. The ward nurse is about to ask you some
questions to verify your identity. Answer his/her questions with the following information.

• Name: Shannon Chow

• DOB: 23/08/1975
• Allergy: nuts
The nurse has come back to ask a few additional questions. Answer his/her questions using the following
information.

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• Reason for admission: to get a chest x-ray

• Past illness: pneumonia (2 years ago)
• Past operation: appendectomy (when 14)
• Current medication: aspirin for arthritis (daily)
• Next of kin: Jenny Chow (sister)

ROLE-PLAY 2
You are a hospital ward nurse. A new patient has just been admitted to your ward. You are about to greet
the patient and check the information on his/her identify bracelets. Ask suitable questions to obtain the
information.

What you will have to check:

• the patient’s full name
• his/her date of birth
• whether he/she has any allergy
• whether his/her additional bracelet is of the right color
o red for allergy
o orange for infection risk
o green for fistula
o blue for cognitive impairment

After completing some paperwork at the nurse station, you are with your patient again. Fill out the Patient
Admission Form by asking the patient relevant questions.

Patient Admission Form

Family name:
Given name(s):
DOB:
Ward: 12-F
Physician: Dr. Raymond C. Yan

Date of admission: 25.07.2017

Reason for admission:
Past medical history:
Past surgical history:
Current medications:
Allergies:
Next of kin:
Activity 3

Role-play a conversation between a hospital ward nurse and a patient about to be discharged.

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Student A

ROLE-PLAY 1
You are a hospital ward nurse. One of the patients in your ward, who was admitted for heart arrhythmia
and chest pain 2 days ago, is about to be discharged. Before the discharge, give the patient some lifestyle
advice so he/she will be better able to manage his/her condition at home. Use the notes you made as you
talk with the patient. You may supplement them with any relevant detail as necessary.

 dining out & takeaway ( cook at home, bring lunch to work)

 sodium, trans fat & sugar
 lean protein & vegetables
 smoking
 maintain healthy weight, blood pressure & cholesterol levels

ROLE-PLAY 2
You were admitted to the hospital 3 days ago after a few anxiety attacks and are about to be discharged.
The ward nurse is giving you some post-hospital instructions to help you manage your condition at home.
Interrupt the nurse appropriately and ask questions when you are uncertain about the information you
are given.

Student B
ROLE-PLAY 1
You were admitted to the hospital 2 days ago for heart problems and are about to be discharged. The
ward nurse is giving you some post-hospital instructions to help you manage your condition at home.
Interrupt the nurse appropriately and ask questions when you are uncertain about the information you
are given.

ROLE-PLAY 2
You are a hospital ward nurse. One of the patients in your ward, who was admitted for recurrent anxiety
attacks 3 days ago, is about to be discharged. Before the discharge, give the patient some lifestyle advice
so he/she will be better able to manage his/her condition at home. Use the notes you made as you talk
with the patient. You may supplement them with any relevant detail as necessary.

 sleep for >7 hours/ day

 try meditation
 socializing

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 caffeine intake
 alcohol consumption
 smoking & recreational drugs

C. Writing Assessment and Narrative Notes Related to Patient Care

1. What are Nursing Narrative Notes?

Different organizations may choose a different format for their nursing documentation process. In
general, nursing narrative notes communicate information on everything that has occurred to a patient
such as admission, treatments offered and medications administered, transfer and discharge, and trace
the patient’s progress toward the desired clinical outcomes by recording any change in his/her condition
and his/her response to interventions. Their purpose is to enable doctors and nurses to analyze the
patient's condition and make appropriate medical recommendations.

While categories differ in terms and numbers, narrative notes often include the patient’s problem,
assessment, intervention, outcome and recommendation.

Problem: What is the patient’s chief complaint?

Assessment: What is observed about the patient’s condition? What do test results reveal?
Intervention:
What has been done concerning the patient’s care?
Outcome: How did the patient respond to the intervention? Did the condition improve or
deteriorate?
Recommendation: What is planned regarding the patient’s future care?

1.1 Practice
Read the narrative note entries of a patient admitted to a hospital’s pediatric ward. Mark the different
types of information with the following symbols.

Problem :
Assessment :
Intervention :
Outcome :

Date: 2/7/2017
09:40 NURSING
Billie is describing increasing pain in left leg. Pain score increased. Paracetamol given, massaged area
with some effect. Education given to Mum at the bedside on providing regular massage in conjunction
with regular analgesia. Continue pain score with observations.
10:15 NURSING
Episode of urinary incontinence. Billie quite embarrassed. Urine bottle placed at bedside.

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14:30 NURSING
Routine bloods for IV therapy taken, lab called -- low Na+. Medical staff notified, maintenance fluids
reduced to 5ml/hr. Repeat bloods in 6/24. Encourage oral fluids and diet, if tolerated, IV can be removed.
Recommendation : #
Source from which the entries used in this activity were adapted:
Linton, S, & Moon, K. (2014). Nursing documentation. Royal Children’s Hospital Melbourne. Retrieved from
http://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Nursing_documentation/

2. Language Points:

2.1 Keep it Succinct

The language used in narrative notes should be direct, simple and reader-appropriate; the tone should
be objective without personal opinion or judgment. Descriptive and observation statements are
preferred over vague descriptors such as “fair” and “poor”. The notes should focus only on the specific
issue being charted.

• For example, a patient with a history of diabetes who also presents a skin problem does not demand
detailed charting of his diabetic history. Instead, chart only information that is or could be relevant
to the patient's skin problems.

2.1.1 Practice

Identify any generalization or judgment in the following sentences. Rewrite them so they are more
appropriate for nursing notes.

1. The patient is still extremely uncooperative today.

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_________________________________________________________________________________

_________________________________________________________________________________

2. The patient has developed an addition to analgesics

_________________________________________________________________________________

__________________________________________________________________________________
3. The patient is in a lot of pain.

__________________________________________________________________________________

__________________________________________________________________________________

2.2 Make it Comprehensible

Narrative notes should be short, but if it needs to convey a significant amount of information, break it
into paragraphs for easy scanning. To save time, space and improve communication efficiency without
increasing risks of clinical errors that could be resulted from any misinterpretation, only abbreviations
that comply with the organization and departmental guidelines of hospitals or clinics should be used. If
abbreviations for two similar conditions or treatments look very similar, avoid using them altogether
and instead write out the full names of the conditions or treatments. Notes written by hand should be
clear so as to avoid the risk of giving an incorrect medication or dosage based on bad handwriting.

2.2.1 Common Abbreviations and Acronyms

Table 1 below provides a quick reference to some commonly used abbreviations and symbols
throughout the profession. Some institutions, however, may have their own abbreviations for
practitioners to follow such as those listed on the site below.

https://abbreviations.yourdictionary.com/articles/nursing-abbreviations.html

Table: 1

Abbreviations with/without a slash: Abbreviations with the letter ‘x’:

B/C because Bx biopsy
C/C chief complaint Dx diagnosis
Cl client Hx history
C/O complained of Ix investigation
C/S culture and sensitivity Mx monitoring test
D/T due to Rx prescription
D/W discussed with Sx symptom
D5W 5% dextrose in water Tx treatment
F/U follow up
H/O history of

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I/O: -210 intake is 210 cc less than output

L/min liters per min
N/C nasal cannula
O/E on examination
OD overdose
R/O rule out
W/, W/O with, without
Abbreviations for time: Abbreviations for dosage:
3/7 3 days o.d. once a day
6/52 6 weeks b.d./b.i.d. twice a day
1/12 a month t.d.s./t.i.d. three times a day
q.d.s./q.i.d. four times a day
o.m. every morning
o.n. every night
q.h. every hour
q.q.h. every 4 hours
p.r.n. when required
a.c. ante cibum (before food)
p.c. post cibum (after food)
Acronyms for tests: Other abbreviations/symbols:
BP blood pressure increased
FBC/CBC full blood count/complete blood count decreased
RBC red blood cells
3x, 4x, etc. 3 times, 4 times, etc.
WBC white blood cells
x 3 days for three days
ESR erythrocyte sedimentation rate
ad lib at will
BGLs blood glucose levels
amt amount
U&E urea and electrolytes
appt. appointment
LDL low density lipoprotein
FiO2 fraction of inspired oxygen
HDL high density lipoprotein
HbA1c glycated haemoglobin
LFTs liver function tests
L left
TFTs thyroid function tests
R right
MSU midstream urine sample
pre-op pre-operation
HVS high vaginal swab
post-op post-operation
CXR chest X-ray
kvo keep vein open
AXR abdominal X-ray
min, mod, minimum, moderate,
KUB kidneys, ureters and bladder X-ray
max maximum
CT scan computerized tomography
per according to
MRI scan magnetic resonance imaging
pt patient
USS ultrasound scan
re on the subject of / regarding
stat immediately
Other common medical acronyms:
BMI body mass index
BMP basic metabolic panel
BP blood pressure
ER/ED emergency room/emergency
department
ECG/EKG electrocardiogram

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GCS Glasgow Coma Scale

(E) (eye response)
(V) (verbal response)
(M) (motor response)
HPI history of present illness
HR heart rate
HTN/HT hypertension
ICU Intensive care unit
IPD inpatient department
OPD outpatient department
IV intravenous therapy
MD medical doctor
MP muscle power
PO by mouth
NPO nothing by mouth
NSAIDs nonsteroidal anti-inflammatory drugs
NTG nitroglycerin
N/V nausea or vomiting
OD oculus dexter (right eye)
OS oculus sinister (left eye)
OU oculus uterque (both eyes)
OOB out of bed
SOB shortness of breath
TPR temperature, pulse, respiration

2.2.2 Practice

Read the following excerpt from a conversation between a patient and his GP. Rewrite the parts
containing abbreviations and acronyms, so the patient has a clear understanding of his test results.

"Mr. Smith, let’s review the results of your blood tests. Your CBC, BMP, and LFTs were basically
negative. You have prediabetes and a slightly elevated LDL, and since your BMI is 28, you should
watch your diet and exercise more to prevent metabolic syndrome. Oh, and it's OK to keep taking
an occasional NSAID with food for your idiopathic knee pain."

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

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Source from which the text was adapted:

Lin, K. (2011, July 25). Decoding doctor-speak: Translations of common medical terms. US News. Retrieved from
https://health.usnews.com/health-news/blogs/healthcare-headaches/2011/07/25/decoding-doctor-speak-translations-
of-common-medical-terms

2.3 Patient Presentation

A narrative note should clearly identify the patient’s presenting problem noticed by the clinical
practitioner or about which the patient complains. Objective measures of patient health, such as blood
pressure and heart rate and subjective measures, such as skin color and whether the patient appears
anxious should be noted.

Sample language:

(i) C/O occasional chest tightness over past few years. Did not see a doctor because felt not serious.
Had chest pain, cold sweats, and difficulty breathing. Felt faint at work yesterday around 10:00 a.m.

Tip 1: Omit the subject if it is the patient.

Tip 2: When the subject of the main clause and that of the subordinate clause are the same, both
subjects can be omitted. For example,

The patient did not see a doctor because he felt it was not serious. → Did not see a doctor
because felt not serious.

(ii) Conscious, weak, and dizzy. Continues to have black stool.HR: 100/min, BP: 94/48 mmHg. Preparing
IV drip. Waiting for endoscopic examination. Told patient to be NPO.

Tip 1: Omit the subject if it is the nurse. For example,

The nurse told the patient to be NPO. → Told patient to be NPO.

Tip 2: Omit the verb to be in progressive tense and passive voice. For example,
The nurse is preparing the IV drip. → Preparing IV drip.
Vital signs are taken. → Vital signs taken.

2.3.1 Practice

With a partner, read the admission interview below between a nurse and a patient. One of you read the
lines as a Nurse and the other as a Patient. Then write a nursing note for the interview.

_____________________________________________________________________________________

_____________________________________________________________________________________

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_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

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Source from which the text was adapted:

Thompson, V. (2018). How to Write a Nursing Narrative Note. Retrieved from https://careertrend.com/how-
8465877-write-nursing-narrative.html

2.4 Assessment

A narrative note should outline any and all assessments administered to the patient, starting with
objective assessments such as blood panels. Other subjective assessments, such as accounts from family
and friends of the patient's state of mind, should be noted as well. The notes should be concluded with

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the probable diagnosis and the findings of any assessment measures. If more tests are indicated or the
patient may be suffering from a disorder that has not yet been diagnosed, this should be noted as well.

Sample language:

(i) Came to OPD due to abdominal dullness and fullness. Blood tests and sonogram done. Ovarian tumor
found on left side. Doctor recommended surgery. Admission completed.

(ii) Diagnosed with cellulitis. No fever. Redness, pain, and warmth in lower ® limb. Worried about
prognosis. Told to take medicine as instructed. Understood recovery takes 7 to 10 days. Well-
accepted. Assisted to elevate lower ® limb.

2.5 Medication and Treatment

After completing the assessment, list any and all medications the patient has been given, as well as the
dosage and mechanism of delivery. If a doctor prescribes medication, list this medication and the
dosage together with any other medications the patient regularly takes.

Sample language:

(i) Told tuberculosis curable if medicine taken as instructed for at least six months and follow-up
examinations done regularly. Told never to stop medication or adjust dosage by himself.

Practice

Read the following narrative in a patient’s nursing notes. Answer the questions that follow.

07/04/2017, 1300 hours:

Tried to get out of bed with one nurse, however, this required assistance of two people. Patient

complained of feeling very dizzy when sitting on edge of the bed. Observations of vital signs were stable

and after a couple of minutes patient able to stand with assistance. Walked several steps in new pink

slippers from daughter with the help of two nurses. Sat out in chair for 10 minutes and then helped back

into bed by one nurse. Dressing to abdominal wound changed. Incision site fine.

-- S Beatles, Staff Nurse

2.5.1 How is the information in the entry organized?

_____________________________________________________________________________________

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2.5.2. Does the entry contain any irrelevant detail? If so, underline the part with the unnecessary
information.

_____________________________________________________________________________________

_____________________________________________________________________________________

2.5.3 The information on the patient’s incision site (shaded in gray) is incomplete. What are some
descriptions that may be found in a good entry?

_____________________________________________________________________________________

_____________________________________________________________________________________
Source from which the entry used in this activity was adapted: Castledine, G. (2003). Writing, documentation and
communication for nurses. Wiltshire, UK: Quay Books.

References:

Allum, V., & McGarr, P. (2008). Cambridge English for nursing: Intermediate plus. Dubai, UAE: Cambridge
University Press.

Boynton, B. (2016). Successful nurse communication: Safe care, healthy workplace, and rewarding
careers. Philadelphia, PA: F.A. Davis.

College of Registered Nurses of Nova Scotia. (2015). Nursing plan of care: Practice guideline. Halifax, Nova
Scotia: College of Registered Nurses of Nova Scotia.

Fortin, A. H., Dwamena, F. C., Frankel, R. M., & Smith, R. C. (2012). Smith’s patient centered
interviewing: An evidence-based method (3rd ed., pp. 29-62). New York, NY: McGraw Hill.

Nursing Abbreviations. (2018). Retrieved from

Su, S. M. (2016). Nursing English for pre-professionals. Taipei, Taiwan: LiveABC.

Silverman, J., Kurtz, S., & Draper, J. (2013). Skills for communicating with patients (3rd. ed.). London, UK:
Radcliffe Publishing.

Thompson, V. (2018). How to Write a Nursing Narrative Note. Retrieved from

https://careertrend.com/how-8465877-write-nursing-narrative.html

Wilson-Stronks, A., Schyve, P., Cordero, C. L., Rodriguez, I., & Youdelman, M. (2010). Advancing effecive
communication, cultural competence, and patient- and family-centered care: A roadmap for
hospitals. Oakbrook Terrace, IL: The Joint Comissions.

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