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Effective Recording and Report Writing for Healthcare

Learn how to accurately document patient information and create clear and concise reports.

1 day
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About this course

It is essential that documentation within our health service is adequate to allow for clear comprehensive communication and to satisfy GDPR requirements.

This one-day intensive training programme will equip delegates with the necessary knowledge and skills to create clinical records and reports that adhere to best practice standards, that comply with GDPR requirements and that will stand up to legal scrutiny.

Course Syllabus

An intensive and highly practical training day, delivered by qualified lawyers. This course will focus firstly on analysing why clinical records are kept and best practice standards in maintenance of good records in compliance with GDPR requirements. It will then look at where professionals fit into the legal system and how their records and reports can be used as evidence in a court hearing. It then goes on to assist attendees in understanding what is required from reports.

This course also considers the content of reports by considering the source and weight of evidence to be included and learning to distinguish between facts, inference and opinion. It considers the type and format of reports. Organisations may submit sample reports from a fictional or completed case in advance of the training. The trainer will review these reports and give feedback to attendees on the day.

Key Learning Points

  • The importance of good record keeping,
  • Understand the function of their records,
  • Understand the function of records and GDPR requirements,
  • Learn the components of good record keeping,
  • Understand how records are used as evidence in legal proceedings,
  • Learn how to create a report with the assistance of their records,
  • Look at appropriate layout, format and style for their reports,
  • Be able to identify the issues and the facts, and the source and weight of those facts,
  • Develop an objective and critical eye in relation to their report writing.

Who should attend

All Medical, Health & Social Care Professionals produce records and reports in the course of their work, which are regularly relied on as evidence in legal cases. If your records and reports fail to stand up to scrutiny this may have serious consequences for both you and your client. This course allows attendees to look at what is required to create records and reports to the required legal, professional and evidential standards.

Available Dates

Course DatesLocationPriceSpaces LeftBook

10/10/2023 09:30 - 16:30

Zoom Online £295 10
Aoife O'Connor

Saint John of God Hospital

I found this course extremely beneficial.

I learned the difference between reports, statements, records and notes. The report template is very useful, plus being able to submit reports & statements for review by the trainer was great. Fantastic trainer.

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La Touche Training Expert Trainers

We work with a wide panel of specialist trainers, all chosen based on their experience and knowledge, experience both in practice and as trained trainers. The majority of our trainers are experienced...

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Learn how to accurately document patient information and create clear and concise reports.