MSRA Communication and Documentation 3

Question 1

During a ward round, a consultant gives a verbal order to change a patient's medication. What is the correct action?

Accepted Answer

Write the order in the notes yourself and wait for the consultant to countersign later

Answer

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?

Accepted Answer

Decline to share information without the patient's consent

Answer

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?

Accepted Answer

A record of the risks, benefits, and alternatives discussed with the patient

Answer

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?

Accepted Answer

Contact the issuing team, correct your own records, and alert the patient

Answer

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?

Accepted Answer

Assess the patient's prior knowledge and readiness before sharing information

Answer

The SPIKES protocol emphasises assessing patient knowledge and readiness (the 'Perception' and 'Invitation' steps) before disclosing difficult news.

(MSRA) Multi-Specialty Recruitment Assessment Practice Test

(MSRA) Multi-Specialty Recruitment Assessment Practice Test

MSRA Communication and Documentation 3