Documentation and Record Keeping

Documentation and Record Keeping Level 2 – CPD Certified - Online Training Course

Welcome to our online Documentation and Recordkeeping training course for front-line healthcare and social care providers. All our online training courses, programmes and qualifications are accredited by the CPD Certification Service (CPDUK).

All healthcare and social care workers should understand the importance of good record-keeping. It is both a legal and professional requirement. Comprehensive records help to:

• Improve communication between health and care professionals,
• Support delivery and continuity of care,
• Demonstrate clinical judgements and decision making, and
• Identify and manage risks appropriately.

Entry requirements - no prerequisites required

Assessment type - Complete end of course assessment (80% needed to pass and gain CPD certificate)

Certification/Qualification - Downloadable CPD certified certificate

Cost(s) of assessment and certification - Assessment and certification costs included in the course price

Course accreditation - CPD Certification Service (CPDUK)

CPD Certified Certificate

Digital certificate - Included

Course aims and objectives

The aims of this Documentation and Recordkeeping e-learning course are to improve health and social care workers’ understanding of the legislative, regulatory and professional requirements for keeping medical/care records appropriately.

Doctors, nurses, midwives, allied health professionals and other health and social care support workers are required to keep clear and accurate records which are relevant to their practice. Patient health records also have a function in improving accountability and in so doing, have a legal purpose in providing evidence of the practitioners’ involvement or interventions about patients or clients.

Learning outcomes

The learning outcomes of this online Documentation and Recordkeeping training course are to:

• Explain why it is essential to maintain excellent clinical/medical records,
• Understand your responsibilities for maintaining good clinical records,
• Explain what constitutes clinical records in practice,
• Understand the legal requirements for record-keeping,
• Know how long clinical records should be kept, and
• Understand how the Data Protection Act applies to your practice.

Why is this Documentation and Recordkeeping course important?

All healthcare and social care workers should understand the importance of good record-keeping. Comprehensive records are essential in healthcare, and all staff need to dedicate time to documentation.

Professional organisations such as the General Medical Council (GMC); Nursing and Midwifery Council (NMC) and the Health and Care Professions Council (HCPC) highlight good record keeping as an integral part of practice and essential to the provision of safe and effective care. They acknowledge that good record keeping has a range of crucial functions including:

• Improving communication between health and care professionals,
• Supporting delivery and continuity of patient care,
• Demonstrating clinical judgements and decision making, and
• Identifying and managing risks in practice.

What is covered in this online course?

This online Documentation and Recordkeeping training course covers the following:

• Why are health records important
• Definition of health records
• Adequate health records
• Who can have access to health records
• Charging for access to health records
• What counts as health records
• How long should health records be kept
• The Data Protection Act 1998
• Data protection principles
• Data protection terminology
• The Data Protection act 1998 rights of data subjects
• Storage, security, and disposal of health records
• References and online learning resources
• Summary.

Documentation and Record Keeping Level 2 – CPD Certified - Online Training Course

• Doctors
• Nurses
• Allied Healthcare Workers
• Healthcare Assistants
• Social Care Support Workers
• Medical Secretaries
• Personal Assistants
• Voluntary Staff working in the NHS

For classroom training courses:

• Bring photo ID (e.g. passport, licence, EU card)
• Wear comfortable clothing

For online courses:

• Access to a computer device, e.g. desktop, laptop, tablet or smartphone device

Our online and classroom training courses are suitable for:

• Those who are looking to improve their knowledge of the subject area
• Those whose jobs require periodic continuing professional development (CPD)
• Those who need to show evidence as part of their professional registration requirements, e.g. doctors, nurses and allied health professionals