Defensible Documentation in Healthcare

Defensible Documentation Training is delivered by live interactive webinar. It is designed to give attendees a better understanding of the principles of good communication and record keeping. Effective communication skills are essential when working in the healthcare sector. The CQC looks to this as a key indicator of good practice.

Course Objectives

After attending this course you will be able to:

• Raise awareness of the importance of keeping defensible documentation and accurate electronic paper records
• Understand the purpose and principles behind quality written information
• Recognise information that is appropriate and inappropriate for recording
• Identify effective and appropriate ways of presenting information
• Understand the need for, and the limits of, confidentiality

Course Content

• Why do we need defensible documentation?
• Written records for healthcare and independent care
• Good practice guidelines
• What should and should not be documented
• Taking and making accurate records
• The use of 'plain English' and minimising the use of jargon
• Keeping records secure
• Confidentiality and GDPR
• Principles of the GDPR
• Defensible documentation
• Legalities
• The potential consequences of poor recording keeping

Suitability

Defensible Documentation Training is targeted at managers, nurses, team leaders, HCA's and support workers who work in hospitals, care homes, community teams, mental health unites, learning disabilities, domicilary agencies and voluntary organisations.