Intended for healthcare professionals
 
CPD modules

Maintaining best practice in record-keeping and documentation

  • Peer reviewed
  • Certificate
  • Learning time: 02 hrs
  • Last updated: 2021
  • Link to RCNi Revalidation Portfolio

This learning module considers best practice in record-keeping and documentation in light of recent public inquiries and reports, and the challenge of moving from paper to electronic healthcare documentation and digital storage of data. Collaborative approaches to planning and evaluating care, and the greater emphasis on patient ownership of information that concerns them, are highlighted.It is important to note that the principles discussed here can be applied to other healthcare environments, notably the care home setting.

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Intended learning outcomes

This learning module for nurses aims to set the nursing practice of record-keeping in the context of recent public inquiries and guidance, as well as current policy and legislation. It discusses the risks, challenges and opportunities of electronic record-keeping. It also considers record-keeping in the context of collaborative working with patients, service users and colleagues from other professions.

After reading this module and completing the time out activities you should be able to:

  • Describe the principles of good information governance.
  • Discuss recent developments in information governance policy and practice.
  • Review the quality of patients, service users or residents clinical records.
  • Assess the quality of patients, service users or residents care plans.
  • Identify sources of further information and guidance on record-keeping.

This learning module is broken down into the following sections:

  • Aims & Intended learning outcomes
  • Introduction
  • Influences on record-keeping
  • Policy and guidance: recent developments
  • Legal, professional and regulatory influences
  • How to write records
  • Conclusions

Disclaimer

Please note that information provided by RCNi Learning is not sufficient to ensure competence in the skill. Assessment of competence should take place in line with local practice. Practice should always align with local protocols and procedures, latest guidelines and any regulatory code. All modules should currently be viewed together with available national and local Covid-19 guidelines. For advice, go to www.rcn.org.uk/covid-19/rcn-position

Jane Beach, Professional officer for regulation, Unite/Community Practitioners and Health Visitors Association, West Bromwich.
Jennifer Oates, Freelance regulatory policy and research consultant, Brighton.


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All our modules include CPD certificates. They are evidence-based and have been subject to an external double-blind peer review.

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Pre and post module tests let you measure your progress. Further reading list included