• Level 2
  • 3 Hours Duration
  • 1 Year Certificate

Effective Record Keeping Training

This effective record keeping training course is aimed at assisting carers to understand what is expected of them in regards to maintaining accurate up to date records and documents.

Gain the required skills

This effective record keeping training course is aimed at assisting carers to understand what is expected of them in regards to maintaining accurate up to date records and documents.

The course will help carers improve their communication skills through teaching best practice documentation and record keeping skills.

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Course Summary

  • Discuss what is communication, types of communication, barriers of communication and the process used to effectively communicate.
  • Examine what is Effective Record Keeping, what we need to record and how much we need to write.
  • Review how we can improve practice, the language we use and recognise information that is appropriate to use
  • Review Laws and Legal Requirements; The Data Protection Act 2018, GDPR, Confidentiality, Accountability and Delegation, Storage, Transportation and Security.
  • Consider where to gain additional advice and support

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Training FAQs

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    Where Do You Deliver The Effective Record Keeping Training?

    We can deliver this training at your premises, as long as it's within the UK. Also, we have our own venues in Stoke on Trent, London, Swindon, Epsom & York if you need access to a training room (additional charges will apply). We can also deliver this training virtually using Zoom. However, sessions delivered via Zoom will be theory only and will not include any practicals.

    How long will the training last?

    This training will last 2-3 hours. We give a range of time to account for variable factors such as; underlying knowledge and competence of delegates, class interaction and engagement and reduced delegate numbers. If a course finishes earlier than the allotted time, it will be due to one of these reasons. However, our trainer will ensure that all learning outcomes have been met.

    How Many Delegates Can I Have On One Session?

    We will deliver this training for a group of up to 12 delegates. Similarly, for larger groups we can either provide multiple trainers on the same day or run multiple days to get everyone trained.

    Who Will Conduct The Training?

    One of our expert clinical tutors. These are either Nurses or Doctors with abundant clinical and complex care experience and knowledge - so you'll be in great hands! We will let you know who is doing the training in advance. You can check out their skills and experience by finding them on our meet the team page.

Effective Recording Keeping Training Course

In today’s information-driven world, the practice of maintaining accurate records is more vital than ever. Organisations rely on well-organized records for decision-making, accountability, and communication.

However, the complexities of legal requirements and the increasing volume of data can make record keeping challenging. This course aims to deepen participants’ grasp of the pivotal role that effective record keeping plays in diverse professional contexts.

Whether you work in healthcare, education, business, or any other field, having a strong foundation in effective record keeping is essential for your professional growth and the success of your organisation.

Participants will be empowered to actively contribute to accurate and compliant record keeping practices within their specific fields.

At course completion, participants will possess the knowledge and skills necessary to maintain meticulous records that positively influence decision-making, accountability, and communication within their organisations.


Course Duration 2-3 hours
Course Level Level 2
Certificate 1-year certificate
Max Delegates 12
Practical Yes


CPD Approved: For effective record elearning course- click here -cpd


Course Objective:

This course is designed to help you become more aware of the significance of effective record keeping in various contexts.

By exploring fundamental principles and legal considerations, you’ll gain insights that will empower you to actively participate in accurate and compliant record keeping practices within your professional sphere.

Effective Record-Keeping Course Outline:

Module 1: Why Records Are Important

1.1 What Are Records?

  • Understanding the concept of record keeping and its role in modern workplaces
  • Exploring real-life scenarios where accurate records make a difference

1.2 Why Accurate Records Matter

  • Delving into the advantages of maintaining well-kept records
  • Examining case studies that highlight the impact of accurate records on organisational efficiency

Module 2: What to Put in Records

2.1 What Information to Write Down

  • Identifying the key information that should be documented
  • Distinguishing between relevant details and extraneous data

2.2 Being Accurate and Complete

  • Implementing strategies to ensure the precision and completeness of records
  • Addressing common challenges and adopting error-reduction techniques

Module 3: Following the Rules and Being Ethical

3.1 Knowing the Laws and Rules

3.2 Keeping Things Private and Secure

  • Emphasizing the importance of maintaining confidentiality and data security
  • Applying best practices to protect sensitive information from breaches

Module 4: Best Ways to Keep Records

4.1 Doing What Your Organization Says

  • Adhering to internal policies and procedures for effective record keeping
  • Understanding the role of consistency in maintaining organized records

4.2 Practical Tips for Good Record Keeping

  • Managing time effectively to update records in a timely manner
  • Implementing organizational strategies for clear categorization and easy retrieval

Module 5: Working Together for Records

5.1 Teamwork and Talking

  • Recognizing how collaboration and communication impact record keeping
  • Promoting a culture of shared responsibility for accurate and consistent records

5.2 Getting Help and Clear Answers

  • Identifying sources of support and guidance for complex record-keeping situations
  • Knowing when to seek assistance from supervisors, legal experts, or experienced colleagues.

Learning Outcomes

  1. Explain what is communication, types of communication, barriers of communication and the process used to effectively communicate.
  2. Identify what is Effective Record Keeping, what we need to record and how much we need to write
  3. Explain how we can improve practice, the language we use and recognise information that is appropriate to use.
  4. Identify Laws and Legal Requirements; The Data Protection Act 2018, GDPR, Confidentiality, Accountability, and Delegation, Storage, Transportation, and Security.
  5. List where to gain additional advice and support.

Course Duration and Certification

The Effective Record Keeping training course is a 3-hour course that will help you improve your record keeping skills. Upon successfully completing the course, we will award you a Level 2 Record Keeping Certification.

This certification demonstrates your commitment to professional development and your ability to handle sensitive information with precision and integrity.

Benefits of Certification

  • Demonstrates commitment to professional development
  • Ability to handle sensitive information with precision and integrity
  • Valuable credential

Question and Answer

Will attending this training make me competent?

In short, no. No classroom-based training course can give you full competency – be very wary of anyone claiming they can. Our classroom-based assessments are designed to bridge the gap between classroom learning and workplace competency. We will be sure to provide you with the relevant workbooks and competency proformas to be observed and signed off within the workplace according to your local policy.

What equipment will you use for training?

A: We have a variety of different training equipment and tools available. The training will be relevant and transferable. However, if you have a specific requirement for a particular type of equipment, please make this clear during the booking process, and the team will ensure this is provided.

Alternatively, we can use your own equipment for training.

Why Learn Effective Record Keeping from Us?

The course is led by a trained expert who has extensive experience in record keeping. The course is interactive and engaging, and participants will have the opportunity to practice their skills through hands-on exercises.

By attending the Effective Record Keeping training course, you will gain valuable insights into best practices for record keeping. You will also learn how to make informed decisions and ensure the integrity and confidentiality of important information. We have a dedicated online course on GDPR and Data Protection. Visit the link to start the course.

Here are some of the key benefits of attending the Effective Record Keeping training course:

  • You will learn how to record information accurately and securely.
  • You will learn how to comply with data protection regulations.
  • You will learn how to use appropriate language in your records.
  • You will gain valuable insights into best practices for record keeping.
  • You will be able to make informed decisions about record keeping.
  • You will be able to ensure the integrity and confidentiality of important information.

What are examples of good practice in record keeping?

1. Clear Documentation:
Recording information in a neat and organized manner ensures that anyone who accesses the records can quickly understand what’s written. Clear documentation minimizes confusion and helps prevent errors or misinterpretations when using the records for decision-making or reference.

2. Consistent Updates:
Regularly updating records keeps them current and accurate. When information changes or new data is added, it’s essential to reflect these updates promptly. Consistent updates maintain the reliability of the records over time and prevent the accumulation of outdated or incorrect information.

3. Secure Storage:
Storing records securely, whether in physical files or digital databases, protects them from unauthorized access, tampering, or loss. Secure storage ensures that confidential information remains confidential and maintains the integrity of the records.

4. Accurate Language:
Using precise and clear language when recording information helps to convey facts accurately. Ambiguous or vague language can lead to misunderstandings and potential errors. By using accurate language, you ensure that the records convey the intended message without confusion.

5. Ethical Handling:
Respecting ethical guidelines, particularly in terms of confidentiality and privacy, is crucial when handling records. Only sharing relevant information with authorized individuals and maintaining confidentiality builds trust and safeguards sensitive data. Ethical handling of records also ensures compliance with legal requirements and industry standards.

Why is record keeping important in health and social care?

Record keeping is very important in health and social care for these reasons:

  1. Good Care and Safety: Keeping accurate records helps caregivers provide the right care to people. This keeps them safe and healthy.
  2. Remembering What Happened: Records help us remember what treatments and help people got before. This helps when we need to care for them again.
  3. Following the Rules: Caregivers need to do things the right way and protect people’s privacy. Good record-keeping makes sure they follow these rules.
  4. Learning and Checking: Records help us learn what works best for people’s health. We can also check if everything was done correctly and improve if needed.
  5. Working Together: Different people might care for someone in health and social care. Records help them talk and work together to give the best care.
  6. Making Things Better: Looking at records helps find ways to make care even better. This helps people have the best health and quality of life possible.

In short, keeping good records helps make sure people get the right care, keeps caregivers accountable, and helps improve health and social care for everyone.

What is the NHS policy on record keeping?

The NHS (National Health Service) has a strict policy on record keeping to ensure accuracy, confidentiality, and proper management of patient information. The policy emphasizes the importance of maintaining complete and reliable records for delivering high-quality care. Key aspects of the NHS policy on record keeping include:

  1. Accuracy and Completeness: Maintain accurate, up-to-date, and complete records of patient information and treatments.
  2. Confidentiality and Consent: Safeguard patient privacy, obtain consent, and restrict access to authorized personnel.
  3. Data Protection and Security: Implement robust security measures to protect records from unauthorized access, loss, or breaches.
  4. Timeliness and Ownership: Record entries promptly after interactions, and clearly indicate the responsible healthcare professional.
  5. Record Sharing and Communication: Share records securely among authorized caregivers while respecting patient consent and confidentiality.
  6. Review and Training: Conduct regular audits, reviews, and provide training to ensure compliance, accuracy, and consistent practices.

Which Acts relate to record-keeping?

In the UK, several Acts relate to record keeping, particularly in sectors such as healthcare, data protection, and financial services. Some key Acts include:

  1. Data Protection Act 2018: This Act governs the processing and protection of personal data, including record-keeping practices, data security, and individuals’ rights.
  2. General Data Protection Regulation (GDPR): Although an EU regulation, GDPR has been incorporated into UK law through the Data Protection Act 2018. It sets rules for the collection, processing, and storage of personal data.
  3. Freedom of Information Act 2000: This Act allows the public to request access to information held by public authorities, promoting transparency and accountability.
  4. Health and Social Care Act 2008: Pertaining to the healthcare sector, this Act establishes requirements for record-keeping in health and social care services.
  5. Financial Services and Markets Act 2000: In the financial sector, this Act outlines record keeping requirements for financial services firms to ensure regulatory compliance.

These Acts play a crucial role in guiding record-keeping practices, protecting privacy, and maintaining transparency across various sectors in the UK.

How Long Are Medication Records Kept?

The retention period for medication records can vary based on regulations, organizational policies, and the specific context of healthcare services.

Generally, medication records are often kept for a minimum of 8 to 11 years after the last entry or after a patient’s last interaction with a healthcare facility.

However, this duration can vary depending on factors such as legal requirements, patient age, and the nature of the healthcare facility.

It’s essential to consult specific guidelines and regulations applicable to your region or healthcare setting for accurate information regarding medication record retention periods.

What are good record-keeping practices?

Good record-keeping practices include:

  1. Accuracy: Ensure that the information you record is precise and true.
  2. Completeness: Include all relevant details to provide a clear picture.
  3. Timeliness: Record information promptly after events occur.
  4. Relevance: Focus on important and pertinent information.
  5. Clarity: Use clear language and avoid jargon.
  6. Consistency: Follow standard formats and guidelines.
  7. Security: Safeguard records from unauthorized access.
  8. Confidentiality: Respect privacy and handle sensitive data appropriately.
  9. Organization: Keep records orderly and easy to find.
  10. Retention: Follow appropriate retention schedules.
  11. Accountability: Sign entries with your identity to establish responsibility.
  12. Review: Periodically check records for accuracy and relevance.
  13. Training: Stay updated on best practices and guidelines.
  14. Ethics: Handle records ethically and transparently.
  15. Communication: Share records with authorized personnel effectively.

Following these practices ensures records are reliable, secure, and contribute positively to decision-making and accountability.

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