Clinical Record Keeping

Clinical Record Keeping

Course Length:

3 hours

Maximum Number of Attendees:

12

Course Description:

Record-keeping is an essential part of working in health and social care. This course is aimed at all healthcare professionals, whether you need to refresh the knowledge of existing staff, update their knowledge, or as an induction for new starters.

We provide you with information on industry best practice in regard to clinical record keeping. This training covers the importance of record-keeping and “defensible documentation”. It will provide information on the types of documents used in the workplace. 

To help prepare you for completing records in a correct and competent manner we look at poor practice for record keeping and good quality records, differentiating between fact and opinion, and avoiding jargon in records.

Records should be confidential and stored in accordance with GDPR and we will provide you with the knowledge and understanding on keeping records secure and confidential.

Learning Outcomes and Assessment Criteria:

What this course offers:

• Introduction – Importance of Record Keeping:

  • Define the term “defensible documentation”

  • Identify the types of documents used in the workplace and explain their relevance to good practice

  • Explain the consequence if completing records inadequately or incorrectly

• Purposes and Principles behind good written information:

  • Examples of poor practice for record keeping using case studies

  • Complete good quality records and logs according to best practice guidelines

  • List examples of what should be documented in a person’s care plan

  • Differentiate between fact and opinion when writing records

  • Explain the importance of using a functional level of English writing and not using jargon terminology in records

• Security and Confidentiality

  • Explain how confidential records should be stored in accordance with GDPR

  • Outline the key features of Caldicott Principles

  • Know what to do if they have any concerns regarding security and confidentiality of records

At the end of the training session, there is a written assessment to evidence the learning of the attendees.

This course can be tailored to the bespoke needs of the customer.  Please speak to a member of the sales team for further details.