Professionalism in Documentation for Healthcare Professionals

About this course

Records are how care is communicated between professionals, how decisions are explained, and how care is judged later by patients, employers, regulators and courts. Most healthcare professionals write records every day, yet record-keeping is one of the most common weaknesses identified in complaints, clinical negligence claims and fitness to practise cases. Poor records can put patients at risk; dishonest records can end careers.

This course covers why documentation matters, the principles of professional record-keeping, practical techniques including electronic records and new digital tools, how to correct errors properly, honesty in non-clinical documents such as CVs, fit notes and claims, the role of records in regulatory processes, the standards of each UK regulator, and how to respond to and remediate documentation concerns.

CPD Value and How to Record It:

This course is designed to provide approximately 2 hours of learning, including reading, the reflection points, the reflective account and the assessment. In the UK, CPD is generally recorded as the time actually spent learning, so you should record the time you genuinely spend, which may be more or less than the estimate.

How the course fits your revalidation or CPD requirements depends on your regulator. For example, the NMC asks nurses, midwives and nursing associates to record 35 hours of CPD over three years, of which at least 20 must be participatory; self-directed online learning such as this course usually counts as individual learning unless you complete it with others. The GMC expects doctors to reflect on CPD for appraisal and revalidation rather than setting a fixed number of hours. The HCPC, GDC, GPhC, GOC, GOsC and GCC each set their own CPD requirements, so check the current rules that apply to you. Always keep your certificate together with your written reflection.

What you will learn

• Explain why accurate, timely documentation matters for safety, law and regulation.
• Apply the principles of honesty, objectivity, clarity and accountability to records.
• Use effective note-keeping techniques, including in electronic records.
• Correct errors and make late entries properly, without altering the record.
• Maintain integrity in non-clinical documents, forms and written communications.
• Describe the documentation standards of UK regulators and the CQC.
• Recognise documentation breaches and plan effective remediation.

Who this course is for

All UK healthcare professionals, including those responding to a concern about record-keeping or probity in documents.

Social workers: this cross-profession course covers principles that apply across health and social care; most worked examples come from healthcare settings.

Course content

10 sections · 2 CPD hours · 15 MCQs

Course facts

CPD value

Approximately 2 CPD hours (estimated learning time, including reflection and assessment)

Format

Self-paced reading with record-keeping examples, reflection points and a written reflective account

Standards covered

GMC Good medical practice; NMC Code standard 10; GDC Standards for the dental team; HCPC Standards of conduct, performance and ethics; GPhC, GOC, GOsC and GCC standards; CQC Regulation 17; UK GDPR and the Data Protection Act 2018; Records Management Code of Practice

Assessment

15 scenario-based multiple-choice questions; pass mark 12 out of 15 (80%)

Questions about this course