AIMS
To be able to document and report to ensure that records are defensible
LEARNING OUTCOMES
By the end of this course you will, be able to
- Understand what Defensible Documentation is
- Be aware of relevant legislation
- Recognise how to document information effectively and accurately
- Understand the Caldicott Principles and how to implement them
- Know the impact of Defensible Documentation through case studies
- Recognise which documents need to be 'Defensible'
- Know how to write Defensible Documentation
- Know how to accurately report information
- Understand when and how to use appropriate methods of reporting
- Be aware of some common documentation errors
LESSONS AND TOPICS
Defensible Documentation
- What is Defensible Documentation?
- Questions to ask yourself
- The importance of Writing
Which Documents
- Which Documents need to be Defensible
- Records of Care
Legislation
- Health and Social Care Act
- Care Standards Act
- Data Protection Act
Key Questions
- The Key Questions
- Who?
- What?
- Why?
Data Protection
- Data
- Data Forms
- Caldicott Principles
- Need to Know
How to Write Defensible Documentation
- Plain English
- Objective vs Subjective Reports
- Tips for Well-Written Records
- Common Errors
Case Studies
- Missing Records
- Meyer vs Gordon
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