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This conference focuses on a practical guide to effective records management and improving health and care documentation. There will be a focus on educating and training frontline staff in good documentation, records standards and requirements for record keeping, and learning from complaints, claims and coroner’s inquests to improve record keeping practice. The conference will discuss underlying standards and principles and include guidelines on topics such as legal, professional, organisational and individual responsibilities when managing records. We will hear from a Coroner on their perspective on documentation on record keeping and how improvements could be made. There will be an extended focus on ensuring records are patient focused and involving patients in their health and care record.
The conference will continue with an extended session on the Caldicott principles and sharing information within the health and care record and will demonstrate good practice through interactive case studies. Preventing inappropriate access to records will be discussed.
The conference will discuss paper and electronic records including handwritten clinical notes, emails, care plans and observation charts, and the standards that apply to all records regardless of the media they are held on.
The conference will also discuss ensuring you are compliant with the new Personalised care planning standards which came into force on 31st January 2024.
Personalised care planning standards will help to enable people to manage their own care, with the support of a wide range of services including GPs, hospitals, occupational therapy and social care. This new standard will help citizens and health and care professionals get the right information when they need it, in order to personalise care, and improve the experience for the patient, their carer and their families.
PRSB 2023
Record keeping is essential to the provision of safe and effective care… Records include anything that refers to the care of the patient and records can be called in evidence as part of coroners inquests or criminal proceedings, investigations, fitness to practice hearings, serious incident and disciplinary investigations…The approach to record keeping that courts of law adopt tends to be that ‘if it is not recorded, it has not been done’. Good record keeping shows how decisions related to patient care were made, while poor record keeping increases the risk of harm when making decisions.
NHS professionals
This conference will enable you to:
Network with colleagues who are working to improve documentation and record keeping
Learn from outstanding practice in meeting record keeping standards
Reflect on national developments and learning
Learn from cases, claims and coroner’s inquests
Understand legal, professional, organisational and individual responsibilities when managing records
Explore issues around handwritten clinical notes, emails, care plans, diagnosis recording and observation charts
Improve the way you train and support staff to improve documentation and record keeping
Develop your skills in involving patients in their health and care record
Understand how you can improve and assess record keeping practice
Reflect on a coroner perspective on record keeping
Identify key strategies for ensuring information is shared appropriately and this is documented effectively
Prevent inappropriate access to records and ensure an audit trail
Ensure you are up to date with the latest legal developments
Self assess and reflect on your own practice
Supports CPD professional development and acts as revalidation evidence. This course provides 5 Hrs training for CPD subject to peer group approval for revalidation purposes
