Record Keeping and Defensible Documentation

This 3 hour training course will be delivered by a Clinical Nurse Educator with first hand clinical experience, drawing on their own experience and knowledge.

Suitable For:
All healthcare workers across all settings with existing knowledge wanting to enhance their current understanding. Alternatively, those new to healthcare looking to acquire new skills and practice effectively.

Session Aim:
Nursing documentation is the cornerstone of best practice. It serves many diverse, complex and important functions from ensuring consistency of clinical care and good communication between practitioners, to providing evidence in a court of law that patients have received appropriate, high-quality, evidence-based care… or, indeed, that they have not.

This training course is intended to cover the knowledge and principles of good record keeping. Appreciation of the legal, regulatory, contractual requirements around record keeping. Good clinical entries, tools in relation to the record life cycle, skills to assess the quality of your own record keeping.

Learning Outcomes:

• Build on existing knowledge of the principles of good record keeping.
• Understand the regulatory, contractual and legal requirements regarding record keeping.
• Explore the importance of making good clinical entries.
• Learners will gain specific tools in relation to the record keeping lifecycle.
• Develop the skills to assess the quality of your own record keeping.
• Learners will examine x 2 case studies to review the implications and consequences which
  may arise as a result of breaches to their professional code of conduct