Arrives

Seeking treatment or care can be a stressful and daunting experience, particularly when a person does not know what to expect. Open, honest, respectful and tailored communication can help reduce a patient’s anxiety.

Establishing a rapport with your patient builds trust and helps to elicit information about their preferences, clinical history and goals of care. Communicating effectively with your patient at admission is important to ensure that you obtain all the relevant information you need to help inform your clinical assessment and make appropriate care decisions.

Improving identification rates of Aboriginal and Torres Strait Islander people in health service organisations has been prioritised as part of the Australian and all state and territory governments’ commitment to Closing the Gap though the Council of Australian Governments and the National Indigenous Reform Agreement.

Health service organisations are required to establish processes to accurately identify and record Aboriginal and Torres Strait Islander status. These processes should ensure that all people, regardless of appearance and across all service areas, are asked whether they identify as being of Aboriginal and/or Torres Strait Islander origin.

Obtaining a complete and focused history is a foundation of clinical practice. It requires a combination of effective communication skills, clinical content and clinical reasoning skills. History taking is an experience of sharing between clinician and patient, and to become proficient in this skill a clinician needs patience, perseverance, understanding and practice. By listening carefully to what a patient has to say, together with relevant, logical and constructive questioning, a clinician can acquire a complete clinical history which is imperative for realising a differential diagnosis and in planning care.

Unintentional changes to patients’ medication regimens often happen during hospital admissions, and can cause patient harm during a hospital stay or after discharge.

85% of discrepancies in medication treatment originate from poor medication history taking. Using careful questioning, a clinician can assess what medicines a patient is taking, why and how they are taking it, and the medicine’s effects. Thoroughly reviewing medicines and assessing adherence to medication regimens are actions that contribute to safe and appropriate treatment.

As a leader in your organisation, you have a responsibility to ensure that the systems and processes in your organisation support effective communication and the gathering of relevant patient information at admission. This includes gathering administrative information, information to plan care, screening for risks and partnering with patients about their goals and preferences.

Effective communication is a key requirement of the NSQHS Standards (second edition). The following table describes actions in the NSQHS Standards that are relevant to communicating for safety at admission.

For more information see NSQHS Standards (2nd ed.)

You have a key role and responsibility to effectively communicate with your patient during admission processes.

This requires communication skills in initiating a conversation, building rapport and trust, listening, gathering information and ensuring two-way communication.

Effective communication with your patient and other clinicians involved in your patient’s care will ensure that you have all the relevant information to help inform your clinical assessment, identify any risks, share decisions about care, and take action that is appropriate and reflects your patient’s needs and preferences.

“JMOs play a vital role in collecting and organising the information about patients’ histories and investigations that make it possible for senior staff to arrive at an accurate diagnosis and well-targeted treatment plan. But, if the history is incorrect, everything that follows is at risk” – Victorian Institute of Forensic Medicine.

You are central to your care and have an important role in ensuring that your care goals, preferences and needs are met. You are encouraged to be involved with making decisions about your care, to ask questions, and contribute to communication by being as open and honest as you can be. You have a right to be treated with dignity and respect, and for your healthcare providers to communicate with you about your care.

• Communicating with your healthcare provider when you are in hospital (4 pages)
• Australian Charter of Healthcare Rights (second edition) (1 page)
• Top Tips for Safe Health Care (6 pages)
• Communication in hospitals - Consumer resource about communication in hospitals - Better Health Channel Victoria
• 5 questions to ask before you get any test, treatment or procedure - Choosing Wisely Australia
• Ask Share Know - Information to assist making medical decisions about your care with health professionals 
• Start2Talk - Planning tools with tailored information for each State and Territory - Dementia Australia