As part of an interdisciplinary care team, you must both be able to read and implement the information found in a client’s medical dossier, and to write your own medical notes to contribute to this dossier. You must also be prepared to provide key status updates verbally when speaking with your supervisor, relief person, colleagues and other members of the medical team. When all members of the health care team are able to communicate effectively, the opportunity for human errors—and the deadly consequences of these errors—decreases. Also, the client’s quality of life can increase significantly when you are able to advocate on their behalf.
In this chapter you have learned:
- how to understand and contribute to the medical record
- how and when to use incident reports
- how to recognize your client’s needs and opportunities to improve quality of life
- how to make verbal report and offer suggestions for your client’s wellbeing