CPD modules
Maintaining best practice in record-keeping and documentation
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Course description
This module 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.
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Learning aims and intended outcomes
- 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
Syllabus
- 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
Syllabus
- Introduction
- Influences on record-keeping
- Policy and guidance: recent developments
- Legal, professional and regulatory influences
- How to write records
- Conclusions
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