This eLearning course aims to introduce you to the topic of Recording Information in Health and Social Care.
It begins by describing what is meant by a record, and then outlining the legislation, codes of practice and guidelines related to record keeping.
The course then explains the issue of consent with written records, highlighting the importance of ensuring consent, and in what circumstances the worker may pass over issues without prior consent.
The course then describes in detail good practice in recording information including ensuring accurate, complete, legible records, the difference between fact, opinion and judgement and how to best record these different types of information.
The course then uses real life case studies to illustrate the importance of recording concerns, and of incorporating the individual’s viewpoints in their records.
In the final stage, the course explores how to maintain security of records and details common errors made by staff in maintaining security of information.
The learning outcomes for this course are:
- Explain the legal and good practice framework related to recording information
- Outline the issue of consent
- Identify good practice in recording information including the role of fact and opinion and records as legal documents
- Know what to record and when
- Identify practices that ensure security of information