April 9, 2025 / Last updated : April 26, 2025 Lisa Oosthuizen

Record Keeping

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Course Content

Introduction 5 Topics

Lesson Content

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About this Course

Learning Outcomes

Why Record Keeping Matters

The Principles of Record Keeping 6 Topics

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Honesty and Factual Information

Accuracy and Non-Offensiveness

Confidentiality

Why Do we Keep Records? 7 Topics

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A Communication Tool

Evaluation and Reflection

Evidence of Care Delivery

Assisting with Clinical Decision-Making

Compliance and Auditing

Types of Documentation Used in Healthcare 8 Topics

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Patient / Resident Care Plans (Electronic and Paper-Based)

Assessment Tools

Medical Records

Medical Administration Records (MAR)

Electronic Medicines Administration Records (E-MAR)

Factors That Contribute to Good Record Keeping 6 Topics

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What is Good Record Keeping?

Practical Aspects of ‘Good’ Record Keeping

Additional Considerations for Good Record Keeping

Reflecting on Care Home Environment

Access and Ownership of Health Records 8 Topics

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Understanding Access Rights

Who can Access Health Records?

Access to Deceased Patients’ Records

The Role of the Data Controller

Ownership of Records

Best Practice for Health Professionals

General Data Protection and Its Relevance in Health and Social Care 7 Topics

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Key Principles of GDPR

Retention of Records

Understanding and Reporting Data Breaches

What to do if You Suspect a Breach

Your Responsibilities as a Health and Social Care Professional

Legal Matters and Complaints in Health and Social Care 6 Topics

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When Might Records Be Required for Legal Purposes?

The Legal Weight of Records

Consequences of Poor Record Keeping

Your Responsibilities as a Health Professional

Reflecting on Your Record Keeping 5 Topics

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The Importance of Reflection

Avoiding Common Pitfalls

Final Thought: Your Records Are Your Voice

Useful Resources

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