Good health records are an integral part of safe and effective healthcare, as well as an essential tool in risk management and clinical audit. These records are legal documents. A successful outcome to a Clinical Negligence claim may depend on the quality of the health records. Common errors in record keeping will be highlighted through trainer-led discussions and case studies. The detail of what to include regarding history, examination, diagnosis, information on risks and benefits, consent, treatment and follow up will be discussed.

• Best practice notes in diagnosis, consent, prescribing,
• Treatment and follow up
• Accountablity
• Understanding the legal requirements in relation to records
• Safe use of shared care records
• Use of electronic records
• Implications of the NHS Care Records Service
• Cross-examination to reinforce the importance of record
• Keeping