Record Keeping

Course Title Record Keeping

Course length 2 Hours

Maximum number of delegates, 20 – 60, up to 20 delegates per course

This course is aimed at all staff in health and social care.  

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

Learning Outcome & Assessment Criteria

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 is 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.