Communication and Record Keeping
Communication and Record Keeping - what the exam tests
This domain tests therapeutic communication, barriers to communication, the principles of documentation, reporting, handover and the legal status of records.
Core rules
- Therapeutic communication: active listening, empathy, open-ended questions, reflection, clarification and silence; it is patient-centred and goal-directed.
- Barriers: jargon, noise, language difference, hearing or vision loss, pain, anxiety, preconceptions and false reassurance.
- Documentation principles: factual, accurate, complete, timely, legible, signed with name and designation; approved abbreviations only; chronological order; correct errors with a single line, the word 'error', signature and date - never overwrite or use correction fluid.
- Reporting: verbal reports are followed by written documentation; a deteriorating patient is escalated using SBAR (Situation, Background, Assessment, Recommendation).
- Records are confidential and may be produced in court; the nurse has no right to alter them retrospectively.
Worked example
At 07:00 a patient's respiratory rate rises from 18 to 28/min and SpO₂ falls from 98 % to 90 %. SBAR: Situation - 'Mr X, 60, breathless since 06:30'; Background - 'post-operative day 2, no history of asthma'; Assessment - 'RR 28, SpO₂ 90 % on room air, using accessory muscles'; Recommendation - 'please review now; I have started oxygen at 2 L/min and sat him upright.' Reasoning: SBAR gives the doctor everything needed to act without re-questioning, and the same content is written in the notes with time and signature.
Traps that cost marks
- Charting before the care is given, or charting for someone else.
- Writing opinions ('patient seems difficult') instead of observations.
- Using unapproved abbreviations, or leaving blank lines that can be altered later.
- Failing to document the time you escalated a concern.