Course Overview
Good health records are an integral part of safe and effective care, as well as providing an essential tool in risk management and clinical audit. Common errors and how to create, maintain and use records that will stand up to scrutiny will be highlighted through trainer-led discussions and case studies. The detail of what to include regarding history, examination, diagnosis, prescribing, consent, treatment and follow up will be discussed
Target Staff Group
All clinical practitioners
Course Prerequisites
Must have completed mandatory training on Information Governance, and Clinical Risk Management
Objectives
Understand best practice records for care, treatment and support
Improved communication and importance of accurate record keeping       
Gain clarity on issues of Accountability       
Understanding the legal requirements in relation to record keeping       
Ensuring continuity of care with shared care records       
Electronic records       
Requirements of the NHS Care Records Service 
Delivery Method
Facilitated workshop. Participants will complete a record keeping exercise, scrutinise notes and carry out role-plays focussed on cross-examination
Refresher Period
Not applicable
Duration
1 day course
How to Book
Booked via ESR E-learning User

 

Understand best practice records for care, treatment and support

Improved communication and importance of accurate record keeping       
Gain clarity on issues of Accountability       
Understanding the legal requirements in relation to record keeping       
Ensuring continuity of care with shared care records       
Electronic records       
Requirements of the NHS Care Records Service