NMC CBT·COMMUNICATION-TEAMWORK · Module 2: Communication, Teamwork and Documentation·UnitCOMMUNICATION-TEAMWORK · Unit 02Access: Premium
Unit 2.2: Record Keeping and Documentation
Prepare for Unit 2.2: Record Keeping and Documentation with NMC CBT practice questions covering 4 topics. Part of Module 2: Communication, Teamwork and Documentation — build your knowledge and track your progress with NMC Prep.
What’s in it.
4 topics- Topic 01
NMC Standards for Record Keeping
45 questions - Topic 02
Electronic Health Records and Data Security
45 questions - Topic 03
SBAR Handover
45 questions - Topic 04
Incident Reporting and Learning from Adverse Events
45 questions
Sample questions
3 of manyA few questions from this unit, with the answer and a full explanation. The complete bank is available when you start practising.
A nurse makes a late entry in a patient's record but does not label it as a late entry. What primary risk does this create?
- The entry automatically triggers an NMC fitness-to-practise investigation
- It may appear contemporaneous when it is not, misleading cliniciansCorrect answer
- No risk arises as long as the content of the entry is factually accurate
- The risk is only relevant if the delay was more than 24 hours
ExplanationA late entry in a patient record must be clearly labelled as such, with the actual time and date it was written AND the time and date of the events it documents. Without this label, the entry appears contemporaneous — misleading clinical staff and potentially misleading courts or investigators. If the discrepancy between the entry's apparent timing and other evidence (e.g. electronic timestamps) is later identified, the unlabelled late entry may be treated as an attempt to falsify the record.
A nurse leaves a workstation logged in to the EPR and walks away to answer a call at the nurses' station. What should the nurse have done before leaving the workstation?
- Locked or logged out of the workstation before stepping awayCorrect answer
- Noted the time they left the workstation in the patient's record
- Minimised the EPR window so the screen is not visible from a distance
- Set an automatic screen timeout for 60 minutes as an alternative to locking manually
ExplanationLeaving a workstation logged in to an EPR system and unattended is a significant information governance breach. Any person passing could access patient records without authorisation. The correct action is to lock (or log out of) the workstation before leaving, no matter how briefly. NHS information governance standards and NMC Code Section 5 require nurses to ensure patient data is secure at all times during their shift — not just at log-out at the end of a shift.
Which NICE guideline specifies SBAR as the recommended communication tool for clinical escalation of acutely ill adults?
- NICE Clinical Guideline CG50 — Acutely Ill Adults in HospitalCorrect answer
- NICE Guideline NG5 — Medicines Optimisation
- NICE Guideline NG94 — Emergency and Acute Medical Care
- NICE Quality Standard QS15 — Patient Experience in Adult NHS Services
ExplanationNICE Clinical Guideline CG50 - 'Acutely Ill Adults in Hospital: Recognising and Responding to Deterioration' (originally published 2007) - specifies requirements for clinical escalation of deteriorating patients and underpins NHS trusts' use of SBAR as the structured communication tool for escalation, alongside NEWS2. NG94 covers a different topic (emergency and acute medical care service delivery and organisation) and does not specifically address SBAR. NICE Quality Standard QS15 addresses patient experience at care transitions but does not specifically name SBAR as the required tool.