Communication and Documentation Flashcards

A patient tells you they intend to harm a named third party when they leave hospital. What is the most appropriate action?

Answer: Document the disclosure and inform appropriate authorities to prevent harm

When a patient discloses a credible intent to harm a named third party, the duty to protect overrides confidentiality and requires disclosure to authorities.

Which of the following best demonstrates closed-loop communication during a resuscitation?

Answer: A team member receives a task, confirms understanding, and reports back when completed

Closed-loop communication requires the receiver to confirm the message and report task completion, reducing errors in high-pressure situations.

A patient refuses a blood transfusion on religious grounds despite life-threatening anaemia. How should you document this?

Answer: Document the decision as informed refusal after risks were explained, with the patient's capacity confirmed

A capacitous adult's informed refusal must be documented fully, including capacity assessment and the discussion of risks, even if it results in death.

What is the recommended approach when a patient's advocate disagrees with the documented care plan?

Answer: Listen to the advocate's concerns, review documentation, and engage them in the care planning process

Advocates play an important role in representing patient interests; their concerns should be heard, reviewed against documentation, and incorporated where appropriate.

A junior doctor realises they signed a prescription for a medication they are not familiar with. What is the most appropriate immediate action?

Answer: Contact the prescribing senior, review the prescription, and correct it if needed

Prescribing carries personal responsibility; when uncertain, always verify with the prescribing senior and correct any errors before the medication is administered.

Which of the following is a key principle of good written clinical communication according to GMC guidance?

Answer: Be clear, accurate, legible, dated, timed, and signed

GMC Good Medical Practice requires that records are clear, accurate, contemporaneous, legible, and include the author's identity.

A patient is about to be transferred between hospitals. Which documentation is most critical to ensure safe transfer?

Answer: A comprehensive transfer summary including diagnosis, medications, outstanding investigations, and emergency contacts

Safe patient transfer requires a thorough clinical summary covering current diagnosis, medications, active issues, outstanding results, and emergency contacts.