Course Profile

Course Profile: Report Writing and Record Keeping (1-2 Days)
Workers often regard recording and report writing as a bit of a time waster. This can consequently result in them not recording important information or recording inaccurately. Lack of skills can lead to subjective recording. These factors may lead to confusion, crossed communication, neglect and crisis; outcomes that have emerged in high profile investigations and litigation. This course aims to help learners identify and understand the need for skills and knowledge so as to record their work clearly, accurately and in the appropriate formats and requirements of the organisation.
The course is set within the context of the need to ensure that there is a more consistent standard of recording within all services. Organisations needs to develop recording to more actively respond to the Government’s drive on minimising the use of jargon and the greater use of plain English, making records and reports more accessible to service users. The course is informed by organisation policy, the HCPC standards, CQC fundamental standards and set within the context of the Social Care Commitment
The course provides some knowledge for
NHS KSF: Core 1.2
CIS: 3.4   Care Certificate: Standard 14
QCF: HSC028; SHC021
MIS (2012): 2
The course is designed for 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 purpose and function of recording
  • Why recording needs to be executed in a professional and systematic way and what this means
  • Who sets the standard; references to policies and the BASW Code of Practice
  • How effective recording benefits the service user, worker and the service
  • The potential consequences of poor recording
  • How much to record-fitting purpose
  • The importance and benefits of using simple English
                -how this corresponds with social work values and responds to Government objectives
                -how it can aid in the process of ‘empowerment’ and ‘inclusion’
                -how it can counter passivity & ‘resistance’
  • What is meant by ‘objective’ recording: dealing with our own:
                -Bias
                -Prejudice
                -Assumptions
                -Stereotyping etc
  • How our ‘unconscious can ‘act out’ through recording:
                -Generalisations
                -Unnecessary emphasis
                -Exclusions
                -Additions etc
  • The use of non-judgmental language
  • How jargon and abbreviations can alienate people
  • How recording needs to reflect the Diversity policy
  • The appropriate use of:
                -Headings
                -Subheadings
                -Numbering
                -Introductions
                -Summaries
                -Conclusions
                -Appendixes etc
  • Readability issues; the need to consider:
                -Style
                -Clarity
                -Spelling
                -Grammar
                -General presentation etc
  • Specific recording relating to the organisation’s policies, procedures and processes
  • Confidentiality & Data Protection:
                -What to record
                -Who has access
                -Storage
                -Disclosure
                -The need to know etc
Training methods utilised include: Individual written work, PowerPoint, Word shower method, Pairs work, small and larger Group work, Chalk & Talk, Tutor Presentations, Role Play, Feedback, Handouts, Energisers