FIRST SECTION

 

RECORD KEEPING

MODULE TITLE: An introduction to the general principles of documentation and record keeping in health care: a multi-professional perspective

MODULE OBJECTIVE: Learners to gain insight into the role of the multi-professional workforce in record keeping and documentation

“Verba volant, scripta manent” / "spoken words fly away, written words remain"
Latin proverb - Caius Titus of the Roman Senate

 

CONTENTS:
Click the following links to be taken to the corresponding section of the module:

1. Our Duty and the Data Protection Act 1998
2. What does this mean for us as healthcare professionals?
3. No Standard Model and How Should Record Keeping and Documentation be Captured?
4. Reasons for Legitimate Documentation and Record Keeping
5. What Constitutes a Clinical Record or Document in Health Care?
6. SELF REVIEW SECTION
7. The Consequences of Recording/Documenting Patient Information Incorrectly
8. Useful Documents + References

 

Author: Sarah Osborne

Date published: February 2021