Record Keeping in Healthcare

For Health Care Assistants, Support Workers and Care Staff

Good record keeping is one of the most important parts of delivering safe, high-quality care. Clear and accurate records help ensure that everyone involved in a person's care has the information they need to provide safe, consistent, and person-centred support.

This practical and interactive course will help care staff develop the confidence to document care clearly, objectively, and professionally. Participants will explore common recording mistakes, learn how to capture the patient's voice, and understand how good records protect the individual receiving care, the organisation, and themselves.

Every entry in a care record tells part of a person's story. Poor, unclear, or incomplete records can lead to misunderstandings, missed care, and increased risk, while good record keeping supports communication, continuity of care, and positive outcomes.

This course will provide practical guidance and real-life examples to help care staff feel confident when documenting care and support.

By the end of this course, participants will be able to:

• Understand why record keeping is essential in health and social care.
• Recognise the legal and professional responsibilities associated with documentation.
• Apply the principles of good record keeping in everyday practice.
• Record care clearly, accurately, and objectively.
• Identify common documentation errors and understand how to avoid them.
• Know when and how to make entries in care records.
• Understand the importance of person-centred language and including the individual's voice in records.
• Promote safe communication and continuity of care through effective documentation.

• Why records matter
• Legal and organisational requirements
• The principles of good record keeping
• What should and should not be recorded
• Dos and Don'ts of documentation
• Clear, objective, and factual writing
• Person-centred record keeping
• Supporting communication between care teams
• Learning from real-life examples and scenarios

This course is suitable for:

• Health Care Assistants
• Support Workers
• Care Assistants
• Community Care Workers
• Domiciliary Care Staff
• Residential and Care Home Staff

Accurate records do more than document care. They help colleagues make informed decisions, provide evidence of the care delivered, support safeguarding, and protect both the person receiving care and the staff caring for them.

Good records save time, improve communication, and help deliver safer, better care.

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