Communication, Documentation, and Interprofessional Collaboration
Core concepts
Effective communication is a clinical skill. Know therapeutic techniques (open-ended questions, reflection, clarification, summarization, silence) and non-therapeutic patterns (false reassurance, giving advice, changing the subject, closed questioning). Use structured tools: SBAR for handover, closed-loop communication for critical messages, and teach-back for patient education. Documentation must be timely, accurate, objective, complete, and legible; it is a legal record and should reflect assessments, interventions, and the patient's response. Interprofessional collaboration requires role clarity, mutual respect, and conflict resolution focused on the patient. Confidentiality and privacy apply to every channel, including electronic records and social media.
Traps
Frequent errors include documenting opinions rather than observations, charting before the event occurs, altering a record after the fact without an addendum, and using "patient non-compliant" without context. In communication questions, reassurance and advice are almost always wrong. Another trap is assuming handover is complete when the receiver has not repeated back critical information.
Rule of thumb
If it was not documented, it was not done - and if it was not understood, it was not communicated. Use teach-back and closed-loop confirmation for anything critical.
Worked example
A nurse phones a physician about a deteriorating patient. A poor handover says, "He's not doing well, come quickly." A strong handover uses SBAR: situation (deteriorating respiratory status), background (postoperative day two), assessment (rate 32, SpO₂ 88%), recommendation (urgent review and orders). The physician repeats the key data back, closing the loop.