FRACGP Communication and Documentation 2 — Questions and Answers
Question 1: A GP writes a referral letter to a specialist. Which element is MOST important to include to ensure continuity of care?
- The patient's insurance provider details
- A concise summary of relevant history, current medications, and the specific clinical question (Correct answer)
- The GP's qualifications and registration number
- The patient's employment status and occupation
Correct answer: A concise summary of relevant history, current medications, and the specific clinical question
Referral letters must include relevant clinical history, medications, and a clear clinical question to enable effective specialist consultation.
Question 2: During a consultation, a patient with limited English relies on their adult child as an interpreter. What is the BEST approach?
- Proceed with the family member as interpreter for efficiency
- Use a professional interpreter service, noting that family members may filter or distort information (Correct answer)
- Refuse to consult without a professional interpreter present
- Conduct the consultation in writing using simple English
Correct answer: Use a professional interpreter service, noting that family members may filter or distort information
Professional interpreters maintain accuracy and confidentiality, whereas family interpreters may omit sensitive details or add their own interpretation.
Question 3: Which of the following BEST describes 'active listening' in a GP consultation?
- Taking detailed notes throughout the consultation without interruption
- Nodding regularly to indicate you are hearing the patient
- Reflecting content and emotion, using open questions, and summarising to check understanding (Correct answer)
- Allowing the patient to speak for the full consultation time without redirection
Correct answer: Reflecting content and emotion, using open questions, and summarising to check understanding
Active listening combines reflection, open questioning, and summarising to demonstrate understanding and encourage the patient's narrative.
Question 4: A GP discovers a significant error in a previous consultation note written by a colleague. What is the appropriate documentation action?
- Delete the incorrect note and replace it with an accurate one
- Add an addendum with the date, time, and corrected information, leaving the original entry intact (Correct answer)
- Overwrite the original note with the correction
- Notify the patient in writing before making any changes
Correct answer: Add an addendum with the date, time, and corrected information, leaving the original entry intact
Medico-legal standards require original entries to remain intact; corrections should be documented as dated addenda.
Question 5: When breaking bad news to a patient, the SPIKES protocol is commonly used. What does the 'P' in SPIKES stand for?
- Privacy
- Perception (Correct answer)
- Prognosis
- Plan
Correct answer: Perception
In SPIKES, 'P' stands for Perception — assessing what the patient already knows or understands before delivering new information.
Question 6: A patient sends an email requesting a prescription renewal. Which response BEST adheres to safe prescribing and communication standards?
- Email the prescription directly as it is the most efficient method
- Decline all electronic communication as a policy
- Advise the patient to attend or arrange a telehealth consultation to assess clinical appropriateness before prescribing (Correct answer)
- Ask the patient to describe their symptoms in detail by email before deciding
Correct answer: Advise the patient to attend or arrange a telehealth consultation to assess clinical appropriateness before prescribing
Safe prescribing requires clinical assessment; prescribing via email without consultation compromises safety and regulatory standards.
Question 7: Which of the following is an example of a 'teach-back' communication technique?
- Giving the patient a written information leaflet to take home
- Asking the patient to explain back in their own words what they have understood (Correct answer)
- Repeating the instructions a second time more slowly
- Using diagrams and visual aids to explain the condition
Correct answer: Asking the patient to explain back in their own words what they have understood
Teach-back confirms patient comprehension by asking them to restate instructions in their own words, identifying and correcting misunderstandings.
FRACGP Communication and Documentation 2
A GP writes a referral letter to a specialist.
Which element is MOST important to include to ensure continuity of care?