Good Clinical Record Keeping

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.


  • 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 who enter data onto patent records.

Please speak to us if you would like to arrange a training session.



Contact Details

Company Information

  • Blackstraw Training is a Division of:
    The Data Factory (UK) Ltd
    Registered in England
    Company No.04161217
    VAT No.815 6950 13
    ICO Registration: Z8605788