Our expert trainers
La Touche Training Legal Experts
Healthcare Records on Trial
Learn how to produce professional records which will enhance your credibility as a witness.
Online / In Person
1 day
About this course
In June 2024, HIQA published new national standards to improve management of health information in health and social care services. These standards underscore the necessity for proper information management to ensure high-quality and safe care.
This intensive one-day course is aimed at addressing some of the practical implications of healthcare records for medical, health and social care professionals. It will help you to produce professional records which will enhance your credibility as a witness.
Why choose this course
This comprehensive course equips healthcare professionals, particularly nurses, with essential skills in record-keeping and legal preparedness. Delivered in two focused modules, it ensures participants understand their professional and legal responsibilities in maintaining accurate and defensible healthcare records.
Module 1: Best Practice in Record Keeping (half day)
This module covers the principles of accountability, professional regulation, and duty of care. Participants will explore GDPR and data protection laws, patient consent in record-keeping, and the importance of clear, factual documentation. The session also highlights how well-maintained records can prevent legal complications.
Module 2: Witness Skills (half day)
This module prepares participants for legal scrutiny of their records. Key topics include the distinction between fact and opinion in documentation, statement writing, patient access to records, and the legal process of discovery. Attendees will learn how opposing lawyers examine records and how to confidently stand by their documentation in legal proceedings, including in Coroner’s Court.
Course syllabus
Key learning points
- Accountability,
- Professional Regulation,
- Duty of care to patient,
- GDPR and data protection,
- Patient consent to record keeping,
- The importance of good record keeping,
- Evidence: fact v opinion,
- How good records can save you going to court,
- How to complete statements,
- Patient access to records,
- How your records stand up to scrutiny in legal proceedings,
- The process of discovery in litigation,
- How opposing lawyers look at your records,
- How to stand over your records in the witness box,
- The structure of the Courts, including the Coroners Court.
By the end of this course, participants will have a clear understanding of how to create, maintain, and defend healthcare records effectively, ensuring compliance with legal and regulatory standards while safeguarding patient care.
Who would benefit from this course?
This course is designed for healthcare professionals responsible for maintaining accurate and legally compliant records. It is particularly beneficial for those who may need to present or defend their documentation in legal proceedings.
Professions that would benefit:
- Nurses (including clinical, community, and advanced nurse practitioners),
- Midwives,
- Doctors (GPs, hospital consultants, and junior doctors),
- Allied health professionals (physiotherapists, occupational therapists, speech and language therapists),
- Healthcare assistants,
- Social workers,
- Medical administrators and records officers,
- Healthcare managers,
- Legal advisors in healthcare settings,
- Coroners and risk management officers.
Anyone involved in patient documentation and legal processes within healthcare would gain valuable skills from this training.
Your Trainer
Practical training with small groups to ensure quality.
Our training sessions are not lectures—they're practical, interactive experiences. The small group format allows every attendee to ask questions, take part in discussions involving practical exercises and role-plays.
This method of training allows attendees to put the skills learned into practice immediately. Course participants benefit from the focused attention and guidance of an independent expert.
Register to attend
# SELECTED
| Course Dates | Location | Price | Spaces Left | Book |
|---|---|---|---|---|
| 01/10/26 i 01/10/2026 09:30 - 16:30 | Zoom Online | €295.00 | 11 |
Learn how to maintain accurate and secure patient information
FAQs
Healthcare records may be used as evidence during complaints investigations, inquests, disciplinary matters, regulatory reviews, and court proceedings. Accurate and comprehensive documentation can play a critical role in establishing facts and supporting professional accountability.
This course is suitable for healthcare professionals, nurses, social care staff, healthcare managers, risk managers, legal practitioners, and public sector employees responsible for maintaining or reviewing healthcare records.
A legally reliable healthcare record should be factual, contemporaneous, accurate, legible, objective, and securely maintained in accordance with organisational procedures and legal obligations.
Incomplete, inconsistent, or inaccurate records can undermine evidence, weaken a professional’s credibility, and create additional legal or regulatory risk during investigations or court proceedings.
Records may include patient notes, medication records, care plans, incident reports, safeguarding documentation, correspondence, risk assessments, and electronic health records.
Objective language helps ensure records are professional, evidence-based, and free from assumptions or personal opinion, which is essential when records are scrutinised in legal settings.
Healthcare records contain sensitive personal and medical data, so organisations must ensure records are stored, accessed, retained, and shared in compliance with GDPR and confidentiality obligations.
Records should never be falsified or improperly amended. If a correction is required, it should be made transparently and in accordance with professional and organisational standards.
Clear and accurate documentation supports continuity of care, improves communication between professionals, reduces errors, and assists informed clinical decision-making.
Participants typically develop skills in professional documentation, legal awareness, report writing, evidential standards, confidentiality compliance, and risk reduction through effective record management.
