Record Keeping and Documentation

To provide adequate, appropriate care and to meet legal requirements staff must be able to complete documents clearly and correctly. This course uses exercises and scenarios to support staff in developing and improving their record keeping skills.

Learning Aims

  • Attendees will understand how to use reports and records appropriately.
  • They will know how good or poor record keeping can affect client care and know best practice for accurate documentation.

Course Content

• The importance of record keeping and documentation
• The purpose and function of health records
• Effects of good record keeping
• Effects of poor record keeping
• Legal and professional issues
• Appropriate style and content

Complementary Courses

• Administration of Medication
• Safeguarding Adults at Risk

QCF Links

HSC028 elements 1,2 and 3.

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