Care Records on Trial

Course Outline:

This course is written with all members of a psychiatric patient’s clinical team in mind, but is particularly aimed at those staff who may not fully appreciate the role which clinical notes play within the legal process.

Records, including notes, are an essential tool which care professionals must be able to use effectively to meet their various legal and professional responsibilities.

This interactive course will give you an understanding of how, when and why to write timely and accurate care records, as well as how they can be used to defend your recollection under cross-examination in a courtroom environment.

Throughout the day, with the assistance of a thought-provoking video case study, we will consider who might read what you have written, what should be recorded in care records, what should not be recorded in them and the importance of focusing on not just what was said, but also on what the service user is not saying, as well as their overall presentation.

Towards the end of the day, we will turn to consider what “good” looks like from your and within your role. You will be assisted to formulate a note keeping template which will help you capture all of the relevant information imparted by your service users.

Key Learning Outcomes:

• Describe what a timely care record is
• Describe what an accurate care record is
• Explain why timely care records should be kept
• Explain how timely care records should be kept                                                          
• Use a contemporaneous record to create a report
• Defend your recollection by using a report and contemporaneous record under cross-examination
• Practice contemporaneous record keeping