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WBCHSE HS Vocational Health Care study materials
WBCHSE HS Vocational Health Care study resources

WBCHSE HS Vocational Health Care: Health Care Ethics, Communication and Record Keeping

WBCHSE HS Vocational Health Care · Work through your exam, one topic at a time.

All guide sections

Health Care Ethics, Communication and Record Keeping

Scope

This domain is tested through scenarios: consent, confidentiality, respectful communication, correct documentation and structured handover. Marks go to the principle named, the action taken and the reason for it.

Core rules

  • Four principles: autonomy (respect the patient's choice), beneficence (act for their good), non-maleficence (do no harm), justice (fair use of resources and equal treatment). Veracity is truthfulness; fidelity is keeping promises and loyalty.
  • Informed consent needs information, comprehension, voluntariness and capacity. For a minor in India (under 18) the parent or guardian consents; a competent adult may refuse even life-saving treatment.
  • Confidentiality may be broken only for a legal or public health duty - a notifiable disease, a court order, or serious risk to others - and then share the minimum necessary.
  • Therapeutic communication: open questions, active listening, reflecting, no jargon, no false reassurance, no blaming "why" questions; use an interpreter rather than a family member where possible.
  • SBAR handover: Situation, Background, Assessment, Recommendation.
  • Records are legal documents: write in ink, date and time every entry, sign with name and designation, use only approved abbreviations, leave no blank lines, never use correction fluid or backdate, record facts not opinions, and report incidents on a separate form.

Worked example

A patient's son asks what a biopsy report shows, but the patient has said not to tell him. Reasoning: the duty of confidentiality is owed to the patient, and autonomy includes control over information; so decline to disclose, explain politely that the patient decides who is told, offer to ask the patient whether consent is now given, and record the conversation. The relative's wish does not override the patient's instruction.

Traps that cost marks

Signing for a colleague's care; altering a record after an incident; discussing a case in a lift or on a WhatsApp group; giving false reassurance ("you will be fine"); assuming a 16-year-old may consent alone.