Course Profile

Course Profile: Case Recording (1 Day)
This course aims to introduce learners with the key concepts of effective and professional recording skills. This course focuses on understanding the law and the skills required for recording daily notes professionally and factually.  It is a practical course using exercises to facilitate learning.
The course is informed by the HCPC standards for social care workers and relevant legislation such as the Care Act, the Data Protection Act, the Freedom of Information Act and the CQC fundamental standards
The course provides some knowledge for
NHS KSF: Core 1.2; IK2.2; IK3.2
CIS: 1.4; 3.4
QCF: HSC028; 038
MIS (2012): 2
The course is designed for all health & social care workers required to record in the course of their duty.



Learning outcomes

By the end of the course learners should understand:
  • The importance of recording effectively in terms of protection for the service user, the worker and the organisation
  • Differentiating between fact and opinion
  • Identifying subjective language
  • Recording factually
  • What is meant by ‘objective’ recording; dealing with our own:
          -Bias –Prejudice –Assumptions -Stereotyping etc
  • How effective recording benefits the service user
  • How effective recording benefits the worker and the service
  • The potential consequences of poor recording
  • The use of non-judgmental language
  • How jargon and abbreviations can alienate people
  • How recording needs to reflect the Diversity policy
  • Confidentiality & Data Protection:
          -What to record
          -Who has access
          -Storage
          -Disclosure
          -The need to know etc
Training methods utilised include: Ideas shower, small and larger Group Work, Feedback, Tutor Presentations, PowerPoint, Chalk & Talk, Handouts, Practice Work, Practice studies