Reports and Record Keeping in Health and Social Care

Course Overview:
This course is designed to ensure that all staff understand the importance of accurate, clear, and professional documentation in line with legal, ethical, and organisational standards. Record keeping is not just a regulatory requirement—it is vital for effective communication, continuity of care, safeguarding, and accountability. This course explores the differences between general record keeping and formal reporting, equipping staff with the skills to document care safely and appropriately.

Aligned with CQC, NMC, and Data Protection/GDPR requirements, the course helps improve the quality and consistency of written communication across care settings.

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

  • Understand the purpose and importance of both record keeping and formal reporting in HSC

  • Recognise the legal and professional frameworks that govern documentation (e.g. Care Act, Data Protection, GDPR)

  • Distinguish between routine care records and incident or safeguarding reports

  • Apply key principles of clear, objective, and factual writing

  • Accurately complete daily records, care plans, handover notes, and incident forms

  • Maintain confidentiality and information security in line with policy

  • Reflect on the impact of poor or misleading documentation on individuals and the organisation

Course Details

Duration: 2-3 hours (face-to-face & Virtually via Teams)

Certification Validity: 1 Year

Enquire Here: www.occuteach.co.uk/contact or call 01934 910333