Good Clinical Record Keeping

Training Objective:

This session aims to provide an understanding of how to achieve a consistent and accurate standard of health record keeping throughout the Practice. With the introduction of Pharmacists, Social Prescribers and Paramedics working in general practice, this will give an opportunity to improve data quality. An overview of this can also be included in your Information Governance training.

Covering:

  • The good, bad and ugly - how to record meaningful abbreviations & acronyms
  • Understanding and using  GMC / BMA guidelines to record your work accurately
  • GDPR / Data Protection Act 2018 on record accuracy & relevant sharing of information
  • What should be included in a health record & why
  • Do words matter - how language about the patient can affect clinical decision making
  • Documenting aggressive behaviour

Duration: 1 hour

Who should attend: Suitable for both Clinicians & all other Practice staff. 

We are working with a West Sussex GP who has an interest in promoting best practice for accurate patient record keeping and is keen to provide training for GP's, trainees, Practice Nurses, Pharmacists, Social Prescribers etc.  Please speak to us if you would like to arrange a training session.

 


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