MSRA Communication and Documentation 3 — Questions and Answers
Question 1: During a ward round, a consultant gives a verbal order to change a patient's medication. What is the correct action?
- Carry out the order immediately without documentation
- Write the order in the notes yourself and wait for the consultant to countersign later (Correct answer)
- Refuse to act on any verbal order
- Record it only in the nursing notes
Correct answer: Write the order in the notes yourself and wait for the consultant to countersign later
Verbal orders should be documented contemporaneously in the medical record and followed up with a countersignature at the earliest opportunity.
Question 2: A patient's relative calls the ward demanding information about their family member's diagnosis. The patient is an adult with capacity who has not given consent to share information. What do you do?
- Share the diagnosis as family always have the right to know
- Decline to share information without the patient's consent (Correct answer)
- Share only the treatment plan but not the diagnosis
- Ask a nurse to handle the call to avoid confrontation
Correct answer: Decline to share information without the patient's consent
Patient confidentiality must be upheld; information cannot be shared with relatives without the patient's explicit consent.
Question 3: Which element is most critical to include when documenting informed consent in medical notes?
- The patient's signature on the consent form only
- A record of the risks, benefits, and alternatives discussed with the patient (Correct answer)
- Confirmation that the patient is satisfied with the treatment
- The name of all staff present during the discussion
Correct answer: A record of the risks, benefits, and alternatives discussed with the patient
Informed consent documentation must reflect the discussion of risks, benefits, and alternatives to demonstrate a patient made an autonomous, informed decision.
Question 4: You receive a discharge summary from another hospital that contains an error in a patient's allergy list. What should you do?
- File it without correction as it is another team's document
- Contact the issuing team, correct your own records, and alert the patient (Correct answer)
- Only correct your local records without notifying anyone
- Add a sticky note to the paper file and take no further action
Correct answer: Contact the issuing team, correct your own records, and alert the patient
Allergy errors are a patient safety risk; the issuing team must be notified and local records corrected to prevent future harm.
Question 5: When breaking bad news to a patient, which communication approach is recommended by frameworks like SPIKES?
- Deliver all information at once to get it over with quickly
- Assess the patient's prior knowledge and readiness before sharing information (Correct answer)
- Always have a family member present regardless of patient preference
- Use medical terminology to appear professional
Correct answer: Assess the patient's prior knowledge and readiness before sharing information
The SPIKES protocol emphasises assessing patient knowledge and readiness (the 'Perception' and 'Invitation' steps) before disclosing difficult news.
Question 6: A trainee asks you to help them falsify a logbook entry for a procedure they did not complete. What is the most appropriate response?
- Help them as it will not harm patients
- Refuse and advise them of the professional and legal consequences (Correct answer)
- Report them to the GMC immediately without discussing it first
- Suggest they ask a different supervisor
Correct answer: Refuse and advise them of the professional and legal consequences
Falsifying training records is dishonest and a GMC Good Medical Practice violation; you should refuse and counsel the trainee about professional obligations.
Question 7: What does the Data Protection Act 2018 require when a patient makes a Subject Access Request (SAR) for their medical records?
- Records must be provided within 72 hours
- Records must generally be provided free of charge within one calendar month (Correct answer)
- A fee can always be charged for providing records
- Only GP records are covered by subject access requests
Correct answer: Records must generally be provided free of charge within one calendar month
Under UK GDPR and the Data Protection Act 2018, organisations must respond to SARs within one month and generally cannot charge a fee.
MSRA Communication and Documentation 3
During a ward round, a consultant gives a verbal order to change a patient's medication.
What is the correct action?