Communication and Record Keeping
Overview
Communication and Record Keeping tests therapeutic communication, structured handover and documentation standards. Poor records are a common source of clinical error and legal problems.
Communication skills
- Use simple language, open questions, active listening, eye contact and empathy; avoid medical jargon.
- Non-verbal cues matter: posture, tone and privacy.
- Confirm understanding by asking the patient to repeat instructions.
- Use SBAR for handover: Situation, Background, Assessment, Recommendation.
Documentation rules
- Accurate, complete, timely, legible, dated and signed.
- Record facts, not opinions; write what you observed and did, and the patient's response.
- Correct errors with a single line, initial and date; never erase or use correction fluid.
- Never document care before providing it; if it is not recorded, it is legally treated as not done.
- Store records securely; share only with authorised staff.
Worked example
Handing over a breathless patient: Situation - 60-year-old with worsening breathlessness since morning; Background - admitted two days ago with pneumonia; Assessment - respiratory rate 32/min, oxygen saturation 88%; Recommendation - review now and consider oxygen. This gives the doctor the information in a logical order.
Traps that cost marks
- Writing abbreviations that only your ward understands.
- Back-dating or altering a record after an incident.
- Giving a handover as a story without a clear recommendation.