Documentation in Healthcare
Duration: 30 minutes
Top notch documentation or ‘record keeping’ is crucial to the provision of safe and effective healthcare – it is not an optional extra. This course on Documentation in Healthcare addresses the legislation and guidelines underpinning documentation. It takes the learner through the importance of accurate documentation and explores the consequences of poor quality record keeping.
Objectives
After completing the course, learners will be able to:
Understand best practice and legal requirements for record keeping and documentation
Recognise the importance of documentation
Understand what information needs to be documented and the guidelines for documentation
Be aware of the ‘do’s and don’ts’ of documentation
Topics
Legislation
Data Protection Act 1998
Accountability and responsibility
Principles of good record keeping
Types of documentation
Subjective or objective terminology
Confidentiality
NHS Code of Practice 2003
Documentation do’s and don’ts
Inappropriate documentation
FOI requests