Record Keeping and Report Writing for Care

This course identifies the standards of record keeping/keeping records in accordance with applicable legislation, protocols and guidelines. We will cover the main points of the Data Protection Act. You will recognise how to differentiate between fact, assessment and opinion and how to record conflicting views and perspectives.

What This Course Covers

• Good communication methods and active listening

• Legislation, protocols and guidelines on record keeping

• Standards of record keeping

• Principles and good practice when record keeping

• Health records

• Data protection, confidentiality and information security

• Access to records and delegating record keeping

• The role of records in complaints and civil court cases

• The importance of following correct documentation procedures for CQC inspections

• The importance of ensuring there is a clear audit trail