Unit 2.2: Record Keeping and Documentation

• 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

A few questions from this unit, with the answer and a full explanation. The complete bank is available when you start practising.

1. 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?

   • A
     The entry automatically triggers an NMC fitness-to-practise investigation
   • B
     The entry may appear to be contemporaneous when it is not, potentially misleading clinicians and raising concerns about record integrity
     Correct answer
   • C
     No risk arises as long as the content of the entry is factually accurate
   • D
     The risk is only relevant if the delay was more than 24 hours
   Explanation

   A 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.

2. 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?

   • A
     Locked or logged out of the workstation to prevent unauthorised access to patient records
     Correct answer
   • B
     Noted the time they left the workstation in the patient's record
   • C
     Minimised the EPR window so the screen is not visible from a distance
   • D
     Set an automatic screen timeout for 60 minutes as an alternative to locking manually
   Explanation

   Leaving 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.

3. Which NICE guideline specifies SBAR as the recommended communication tool for clinical escalation of acutely ill adults?

   • A
     NICE Guideline NG94 — Acutely Ill Adults in Hospital: Recognising and Responding to Deterioration
     Correct answer
   • B
     NICE Guideline NG5 — Medicines Optimisation
   • C
     NICE Clinical Guideline CG50 — Acutely Ill Adults (superseded)
   • D
     NICE Quality Standard QS15 — Patient Experience in Adult NHS Services
   Explanation

   NICE Guideline NG94 — 'Acutely Ill Adults in Hospital: Recognising and Responding to Deterioration' (2018) — specifies requirements for clinical escalation of deteriorating patients and recommends SBAR as the structured communication tool. It supports the use of NEWS2 in conjunction with SBAR for escalation. NICE Quality Standard QS15 addresses patient experience at care transitions but does not specifically name SBAR as the required tool.