Reporting and Recording

This training has been designed to enable you to gain an overview into good record keeping practices and how you can use these measures whilst working in the care environment. This course is essential for all staff who under take record keeping and documenting information. The course includes information that has been adapted from and complies with the NMC guidelines on record keeping 2009, the findings of the Caldicott Report 2007, Data Protection Act 1998 and Social Care Codes of Conduct.

This programme aims to develop knowledge and skills to accurately document and record care that is given and to provide an understanding of the process, and formulation of person-centred care plans. It also aims to develop understanding of the Data Protection Act so that you are able to maintain confidentiality in the health and social care sectors.

DESCRIPTION

By the end of this unit on the principles of manual handling and practice you will be able to:

• List the types of documentation used in health and social care
• Maintain accurate recording documents
• Demonstrate effective written communication skills
• Discuss the impact of poor documentation on care provision
• Identify documentation errors
• Discuss the Data Protection Act in relation to your role
• Discuss the concept of confidentiality
• Identify the process’s involved with person-centred assessment and the development of care plans

Course content

 This course covers the following topics:

• Overview of the Data Protection Act
• Principles of confidentiality – The Caldicott Report
• Person consent
• Importance of record keeping
• Guidelines on documentation
• Audit
• Errors in documentation and their outcomes
• Person Centred Care