Record keeping is a challenging concept and as the industry moves away from paper records towards digital records it is more important than ever to ensure that the records we keep are accurate and timely.

Medical records are now freely available to the individual and as such the language used and the information contained within them has to be written in such a way as to promote understanding and remove ambiguity. Furthermore record keeping is a requirement of all those who work in the Health and Social care industry, it is not an optional extra to the role.

• To be aware of the types of records you may be required to keep
• To understand the legal and professional requirements to maintain accurate and detailed resident / patient records
• To ensure that all documentation is recorded in a legible and indelible manner
• To enhance your knowledge around the General Data Protection Regulation in relation to record keeping
• To be mindful of the importance of the duty of confidentiality and appropriate storage of all records
• To understand what actions to take if you believe there has been a data breach in relation to patient / resident or staff records