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Updated: 28 Mar 2025
Health and Social Care
Mandatory Training
Updated: 28 Mar 2025
Updated: 28 Mar 2025
20 People Recommended
Duration Minimum 30 mins
100% Online Course
365 Days Access
Instant Access and Certification
Full Voiceover
The Record Keeping for Healthcare Professionals course is designed to provide healthcare workers, including doctors, nurses, and care staff, with the skills and knowledge needed to maintain high-quality clinical documentation. Accurate and timely record keeping is essential for patient safety, continuity of care, and compliance with legal and ethical standards in the UK.
This course, aligned with the latest NHS standards and UK guidelines, delves into the principles of effective documentation, the legal and ethical frameworks surrounding clinical records, and the integration of electronic health records (EHRs) into daily practice. Participants will learn to create clear, concise, and comprehensive records while addressing challenges such as incomplete documentation, data security, and managing sensitive patient information.
By the end of the course, healthcare professionals will be equipped to uphold excellence in record keeping, contributing to enhanced patient outcomes, efficient communication, and compliance with professional standards.
£20
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Learning Outcomes.
By the end of this course,participants will be able:
To support quality improvement initiatives by maintaining records that facilitate clinical decision-making and team collaboration.
To address common challenges in documentation, including incomplete records, error correction, and ensuring legal compliance.
To utilise electronic health records (EHRs) effectively to enhance patient care, data security, and interdisciplinary communication.
To implement NHS and regulatory guidelines, ensuring compliance with professional standards in documentation.
To apply best practices for creating accurate, clear, and timely records in diverse healthcare settings.
To understand the legal and ethical principles underpinning clinical record keeping, including confidentiality, data protection, and duty of care.
Course
Contents.
01
Introduction to Record Keeping
Principles, purposes, and the role of documentation in healthcare delivery.
03
Professional Standards and Responsibilities
National and regional codes of conduct, roles, and the importance of information governance.
05
Documentation Standards and Practices
Writing clear, concise, and accurate notes while avoiding common errors.
08
Risk Management and Legal Issues
Documenting incidents, managing litigation risks, and navigating complex scenarios.
06
Patient Confidentiality and Information Sharing
Managing disclosure, safeguarding sensitive data, and ensuring interoperability across systems.
09
Practical Documentation Techniques
Using templates, transitioning from paper to digital systems, and adapting to clinical environments.
02
Legal and Ethical Aspects
Overview of GDPR, the Data Protection Act, patient confidentiality, and handling special category data.
04
Technology and Record Management
Effective use of EHRs, ensuring accuracy, privacy, and security in digital documentation.
07
Auditing and Quality Improvement
Using record audits to identify gaps and improve healthcare delivery.
10
Record Keeping in Clinical Contexts
Integrating traditional practices with modern technology in multidisciplinary care settings.
The Record Keeping for Healthcare Professionals course equips participants with the expertise to maintain accurate, secure, and effective clinical documentation. Through practical insights into legal compliance, EHR utilisation, and documentation techniques, participants will contribute to improved patient safety, care quality, and interdisciplinary collaboration, ensuring alignment with UK standards and best practices.
Summary