Clinical Record Keeping.

Who is This Training Course For?

This course is aimed at all healthcare professionals, in particular existing staff to refresh and update knowledge + as induction to new starters in an organisation.

Why do you need this Course?

'Record-keeping is an integral part of Nursing, Midwifery and Allied Health Professionals' practice and is essential to the provision of safe and effective care. It is not an optional extra to be fitted in if circumstances allow' (NMC 2009)

This course will provide you with information on industry best practice in regards to clinical record keeping. You will also learn the importance of patient consent to disclosures of personal information, the means and methods of disclosures and the legal requirements of keeping information secure.

Objectives

• How to provide a confidential service to patients and service users in the context of their specific role
• Understand the principles of Information Governance and how they apply in every day working environments
• How to ensure and maintain good record keeping
• Fundamentals of data protection, confidentiality and the Caldicott Principles
• The responsibilities of healthcare organisations under the Freedom of Information Act 2000
• Your professional and legal responsibilities
• The different types of records used in healthcare
• The importance of good record keeping and the implications of bad record keeping
• Common errors in record keeping
• How to develop your communication skills through accurate and clear record keeping

Course Content

• Aims + Principles
• Legal Aspects
• Codes + Standards
• Accountability
• Countersigning
• Ethical Considerations
• Caldicott Report
• Data Protection
• Freedom of Information
• Patient Information
• Confidentiality + Disclosure
• NHS Protect - Counter Fraud
• Types and Function of Records
• Principles of Good Record Keeping
• Errors and Barriers of Record Keeping