Clinical Record Keeping

Clinical record keeping & effective documentation within the social care sector requires a person-centred approach whilst meeting legislative and information governance requirements. Ensuring that records are effectively and accurately kept, appropriately shared and accessed by multi-agencies and within a social care team can be complex with ever increasing demands, yet the integrity of clinical records and best practice for their management is of paramount importance.

Learning Approach

The course will be highly interactive to include diverse learning and teaching styles to meet individual needs of delegates, whilst following the journey of ‘Joe Brown’s’ clinical health & social care records. Documentation will be evaluated and tracked throughout Joe’s life as he grows, moves and engages with various health & social care organisations.  Using PowerPoint teaching, video discussion and scenario-based problem solving in small groups, delegates will work together to learn the complexities of effectively managing information governance and practice pitfalls when applied to an individual client. The learning outcomes will be measured using Q&A discussion and written evaluation of learning in addition to individual participants sharing and setting goals for their application of the course within their workplace.

Course Content (to be adapted to meet organizational needs and participants expertise)
  • Principles of effective clinical record keeping
  • Meeting needs – a person-centred approach, the law, CQC & good practice.
  • Diverse records and different documents for different purposes
  • Information Governance in the NHS guidelines for staff
  • The Integrity of Records
  • Storing & Accessing Information
  • Information & documentation systems in health & social care
  • Information sharing and the MDT
  • Record Keeping in practice & meeting CQC requirements
  • Safeguarding and clinical records
  • Clinical record keeping Policy & Procedure writing & adherence
  • Errors, Omissions and Negligence
  • Scenario Based Case Studies
  • Discussion
Learning Outcomes
  • state the purpose of different types of clinical records.
  • understand the 4 main rules of effective clinical record keeping.
  • apply an understanding of information governance to record keeping within their role from a case study.
  • plan to apply learning to improve best practice and management of record keeping upon return to their workplace.
Course Length

One Day


The training was excellent. I’ve realised I’ve made mistakes in the past because I was not trained on how to record evidence. After the training I feel confident and good because I’m very aware of how I note evidence down onto our system” Clinical Nurse – Achieving for Children 



Hello! We are able to offer the vast majority of our courses online in a virtual classroom via your preferred video conferencing platform. All of our course contents have been updated to reflect the current COVID-19 situation. To enquire about any of our courses to be delivered online please go to our ‘Contact Us’ page.