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Documentation and Record Keeping

Course Overview

This course aims to ensure the learner is able to complete all required documentation within care so that it complies with both legal and organisational requirements.SUMMARYCare records are legal documents, and may at any time be used in investigations pertaining to the provision of care, adverse incidents, those providing the service or for audit purposes. Figures from the NHSLA Annual Report for 09/10 show that the total costs paid out in this period in relation to clinical negligence schemes was almost £787 million. It is the third year in succession that the figure has risen; £633 million and £769 million were paid out in 07/09 and 08/09 respectively (NHSLA 2010). According to Wood (2010), in medical law, if a care procedure has not been documented then it has not occurred.

  • Explain the purpose of care records
  • Clarify the types of records you are required to complete
  • Explain the legislation and guidance behind this
  • Define your accountability in this process, linking this to confidentiality
  • Explain how to complete care records avoiding the common errors


HTML5 is compatible with Windows using Chrome, Firefox and Internet Explorer 9 or higher, Mac OS X and Apple iPads IOS7 or higher.
Microsoft Silverlight is compatible with Windows using Firefox and Internet Explorer 8 or higher and Mac OS X using Firefox and Safari.
Please note, Silverlight is no longer compatible with Google Chrome.


£10.00 + VAT

Price is per person. Discounts are available for group bookings.

Please be advised all courses expire within 1 year from the date of purchase.

Call 0151 647 1057 for more details.