RNSG 1105: MODULE 3 –
COMMUNICATION AND
DOCUMENTATION EXAM WITH
ANSWERS
I. What are prevention strategies for communication among healthcare team
members?
1. be accurate and complete
2. give concise and factual information
3. be thorough, organized
4. be prompt, timely
5. follow legal guidelines
6. maintain confidentiality
7. Communicate all pertinent information about the patient
8. Communicate data as it happens
9. Review and Verify information
10. Ensure interdepartmental communication
11. Keep patients documents with the patient
12. Develop standardized form or manner for sharing information
II. Review SBAR and how it can assist in preventing communication errors.
-SBAR provides a consistent method for hand-off communication that is clear, structured, and
easy to use by the Health Care Team.
-It is used to:
, RNSG 1105: MODULE 3 –
COMMUNICATION AND
DOCUMENTATION EXAM WITH
ANSWERS
◦ report to a healthcare provider a situation that requires immediate action
◦ define the elements of a hand off of a patient from one caregiver to another, such
as during transfers from one unit to another or during shift report and in quality
improvement reports.
- The goal of SBAR is to decrease miscommunication, which is one of the most
common causes of patient injury or death.
S= Situation, B= Background, A = Assessment, R= Recommendation
III. What are the four main purposes of documentation?
1. A necessary way to communicate with other health care team
2. Used for reimbursement.
3. Establishes a legal record of the patient’s status and care given. Also a source of legal
accountability for the nurse.
4. Used to provide data for nursing research.
IV. What are the guidelines for effective documentation and how do these assist in
preventing errors?
Aim of these guidelines is to provide complete, accurate, concise, current, factual, and organized
data communicated in a timely and confidential manner to facilitate care coordination and serve
as a legal document.
1. Content – should be complete, accurate, concise, current and factual manner.
COMMUNICATION AND
DOCUMENTATION EXAM WITH
ANSWERS
I. What are prevention strategies for communication among healthcare team
members?
1. be accurate and complete
2. give concise and factual information
3. be thorough, organized
4. be prompt, timely
5. follow legal guidelines
6. maintain confidentiality
7. Communicate all pertinent information about the patient
8. Communicate data as it happens
9. Review and Verify information
10. Ensure interdepartmental communication
11. Keep patients documents with the patient
12. Develop standardized form or manner for sharing information
II. Review SBAR and how it can assist in preventing communication errors.
-SBAR provides a consistent method for hand-off communication that is clear, structured, and
easy to use by the Health Care Team.
-It is used to:
, RNSG 1105: MODULE 3 –
COMMUNICATION AND
DOCUMENTATION EXAM WITH
ANSWERS
◦ report to a healthcare provider a situation that requires immediate action
◦ define the elements of a hand off of a patient from one caregiver to another, such
as during transfers from one unit to another or during shift report and in quality
improvement reports.
- The goal of SBAR is to decrease miscommunication, which is one of the most
common causes of patient injury or death.
S= Situation, B= Background, A = Assessment, R= Recommendation
III. What are the four main purposes of documentation?
1. A necessary way to communicate with other health care team
2. Used for reimbursement.
3. Establishes a legal record of the patient’s status and care given. Also a source of legal
accountability for the nurse.
4. Used to provide data for nursing research.
IV. What are the guidelines for effective documentation and how do these assist in
preventing errors?
Aim of these guidelines is to provide complete, accurate, concise, current, factual, and organized
data communicated in a timely and confidential manner to facilitate care coordination and serve
as a legal document.
1. Content – should be complete, accurate, concise, current and factual manner.
