Communication and Documentation Flashcards
7 cards from real RELIAS 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
Which of the following best describes 'therapeutic communication' in a clinical setting?
Answer: Employing purposeful techniques to support patient wellbeing and understanding
Therapeutic communication uses intentional verbal and nonverbal strategies to establish trust and promote patient health.
A patient's advance directive specifies they do not want resuscitation. Where should this information be prominently flagged?
Answer: In a clearly visible location in the electronic or paper chart accessible to the care team
Advance directives must be readily accessible in the medical record so all treating clinicians can act on the patient's wishes in an emergency.
Which behavior represents a non-verbal communication cue that may signal a patient is in pain?
Answer: Guarding a body part and grimacing
Guarding and facial grimacing are nonverbal indicators of pain that clinicians must observe and document.
The minimum retention period for most adult medical records under federal guidelines is:
Answer: 6 years from the date of creation or last effective date
HIPAA requires covered entities to retain documentation of privacy policies for at least 6 years; many states have additional requirements for clinical records.
When a clinical team conducts a 'huddle' at the start of a shift, the primary communication goal is to:
Answer: Share brief, critical patient safety information to align the team
Safety huddles are brief structured meetings designed to surface potential risks and coordinate care before the shift begins.
Which action by a nurse best demonstrates the principle of 'confidentiality' in communication?
Answer: Lowering their voice and moving to a private area before discussing patient details
Moving to a private area protects the patient's confidentiality by limiting who can overhear sensitive information.
An incident report is completed after a patient fall. This document is primarily used to:
Answer: Identify system vulnerabilities and improve patient safety processes
Incident reports are quality improvement tools that analyze events to prevent recurrence, not to assign blame.