Defensible Documentation Training

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6 hours

About Course

The Defensible Documentation Training course focuses on providing healthcare professionals with the essential skills required to maintain accurate, clear, and legally defensible records. By covering key aspects of record-keeping, including legal considerations, confidentiality, and risk management, the course ensures participants create documentation that stands up in both legal and regulatory settings.

What Will You Learn?

  • Understand the importance of creating defensible records to protect both clients and professionals.
  • Learn how to write clear, accurate, and objective documentation.
  • Comprehend the legal implications and responsibilities tied to proper record-keeping.
  • Recognize the procedures for correcting errors and maintaining consistency in records.
  • Understand the role of documentation in mitigating legal risks and enhancing care quality.
  • Apply data protection regulations, including GDPR, to ensure confidentiality and security in documentation.

Material Includes

  • Defensible Documentation training workbook.
  • Sample documentation for practice exercises.
  • Certificate of attendance, valid for 3 years.
  • Access to additional online resources for ongoing reference.

Requirements

  • No prior documentation experience is required.
  • Suitable for all individuals aged 18+ working in healthcare or care settings.

Audience

  • Healthcare professionals, nurses, and support workers responsible for documentation.
  • Managers and supervisors handling documentation processes.
  • Staff across care homes, hospitals, and other health-related settings.
  • Organisations needing to ensure compliance with legal or regulatory documentation standards.

Course Content

Session 1: Introduction to Defensible Documentation

  • What is Defensible Documentation?
  • Legal Implications
  • Compliance and Regulatory Requirements

Session 2: Creating Accurate and Clear Records

Session 3: Correcting Errors and Maintaining Consistency

Session 4: Legal Considerations and Risk Management

Instructors

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