Communication, Documentation, and Interprofessional Practice
Core concepts
Effective communication is a safety competency. Know structured tools: SBAR (Situation, Background, Assessment, Recommendation) for handoffs and escalation, closed-loop communication (read-back) for verbal orders, and teach-back to confirm patient understanding. Use plain language, avoid jargon, and confirm comprehension with the patient or family.
Documentation must be timely, accurate, objective, complete, and legible, following the principle "if it wasn't documented, it wasn't done." Record facts, not opinions; avoid blaming language; correct errors properly (single line, date, time, initials - never obliterate). Know the elements of a complete record and the legal weight of the chart.
Interprofessional practice requires role clarity, mutual respect, and shared goals. Understand conflict resolution, assertive escalation (using the chain of command when a concern is dismissed), and patient-centered team communication. Cultural humility and health literacy awareness improve outcomes.
Traps in questions
- Choosing vague or judgmental documentation over objective description.
- Skipping read-back for verbal or telephone orders.
- Escalating to the wrong person or failing to use the chain of command.
- Assuming the patient understood without teach-back.
Worked example / rule of thumb
A nurse gives a verbal order. The correct response is to write it down, read it back verbatim, and confirm. Rule of thumb: for any high-stakes message, use a structure (SBAR) and close the loop (read-back or teach-back).