Communication and Documentation Flashcards
7 cards from real NMC practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Communication and Documentation flashcards as text
A nurse receives a verbal medication order by telephone. The correct action is to:
Answer: Write down the order, read it back to the prescriber, and confirm before acting
Read-back of verbal orders confirms accuracy and is a critical patient safety step required when verbal orders cannot be avoided.
Which of the following is an example of non-verbal communication that conveys empathy?
Answer: Maintaining appropriate eye contact and leaning slightly forward
Appropriate eye contact and a forward lean signal attentiveness and empathy, reinforcing verbal expressions of care.
A patient's family member calls the ward requesting an update on their relative. The nurse should:
Answer: Verify the caller's identity and check the patient's consent before sharing any information
Identity verification and patient consent must be established before sharing any clinical information over the phone to protect confidentiality.
Under the NMC Code, nurses must be open and honest when something goes wrong. This principle is known as:
Answer: The duty of candour
The duty of candour requires nurses to be open, honest, and apologetic when care has gone wrong, and to document this communication.
A nurse is writing a referral letter to another healthcare professional. The letter should:
Answer: Be factual, concise, and contain relevant clinical information with no jargon
Referral letters must be factual, professional, and clinically relevant, avoiding opinions or unnecessary jargon that could mislead the recipient.
When documenting a wound assessment, which entry is most appropriate?
Answer: 3cm x 2cm wound on right shin, minimal serous exudate, no signs of infection, pink granulating tissue noted
Objective, measurable descriptions using clinical terminology provide the clearest picture of wound status for all clinicians involved in care.
A nurse suspects that a colleague has altered patient records. The nurse should:
Answer: Report the concern to a manager or through the organization's reporting system
Falsification of records is a serious NMC breach; nurses must report concerns through appropriate channels rather than handling it informally or acting unilaterally.