Documentation and Communication Flashcards
6 cards from real LVN practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 6 Documentation and Communication flashcards as text
What is the SBAR communication framework?
Answer: Situation, Background, Assessment, Recommendation — a structured method for clinical communication
SBAR provides a standardized format for communicating critical patient information efficiently.
What are the legal requirements for nursing documentation?
Answer: Accurate, timely, complete, legible, and signed entries that reflect actual care provided
Documentation is a legal record and must accurately reflect all assessments, interventions, and patient responses.
What is a change-of-shift report?
Answer: A structured handoff communication summarizing each patient's status, changes, and care plan
Shift reports ensure continuity of care by transferring essential patient information between nurses.
What should be included in an incident report?
Answer: Factual description of what happened, who was involved, actions taken, and patient outcome
Incident reports document facts objectively without assigning blame, supporting quality improvement and risk management.
What is an advance directive?
Answer: A legal document expressing a patient's wishes about future medical treatment if they cannot communicate
Advance directives include living wills and healthcare powers of attorney, guiding care when patients cannot speak for themselves.
What is therapeutic communication?
Answer: Patient-centered communication techniques that promote understanding, trust, and emotional support
Therapeutic communication uses active listening, open-ended questions, empathy, and reflection to support patients emotionally.