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Accurate and well-maintained records are essential for safe, effective and person-centred health and social care. Good record keeping supports continuity of care, effective communication, safeguarding, accountability and informed decision-making, while poor documentation can create risks for individuals, staff and organisations.
This CPD-accredited Record Keeping in Health and Social Care course is designed for care workers, healthcare assistants, support workers, nurses, managers and other professionals responsible for creating, accessing or maintaining care records. Learners will develop a practical understanding of legal and regulatory requirements, accurate documentation, confidentiality and consent, digital and paper records, incident reporting, safeguarding, quality assurance, audits, record retention, professional standards and continuous improvement.
CPD Accredited
Certificate Included
Learn at Your Own Pace
2 hours
Quizzes covered in each module
Accurate care documentation
Confidentiality and compliance
*For individual learners. Need to train multiple staff? See Organisation pricing
Why This Course Matters
Improve the accuracy and consistency of health and social care documentation.
Support safer continuity of care through clear and accessible records.
Protect confidentiality and handle personal information responsibly.
Strengthen incident reporting, safeguarding and organisational accountability.
Support quality assurance, audits and continuous improvement across care services.
Did You Know?
A care record can provide an important account of a person's needs, the care provided and decisions made over time. Accurate documentation not only supports day-to-day care but can also help organisations identify risks, investigate incidents, demonstrate accountability and improve services.
Why Learn With Carelearner
CPD Accredited Certificate
100% Online & Self-Paced Learning
Instant Digital Certificate on Completion
Works on Desktop, Tablet & Mobile
Industry Best Practice
Earn Your CPD Certificate
Complete the course and pass the final assessment to receive a CPD-accredited certificate ready to download, print and keep on file for inspection.
What's Inside the Course?
Here are the modules you will cover in this course:
Introduction to Record Keeping in Health and Social Care
Introduces the importance of accurate record keeping and explains how good documentation supports safe, effective and person-centred care.
Legal and Regulatory Framework
Explores the legal, regulatory and organisational requirements that influence record keeping, including professional accountability and the importance of maintaining appropriate records.
Accurate Documentation
Covers the principles of clear, factual, timely and accurate documentation, including what information should be recorded and how to avoid common documentation errors.
Confidentiality and Consent
Explores confidentiality, consent, privacy and appropriate access to care information, including the importance of protecting personal and sensitive information.
Digital and Paper Records
Examines good practice when creating, accessing, updating and storing both digital and paper-based records, including maintaining security and ensuring information remains accessible to authorised staff.
Incident Reporting and Safeguarding
Covers the role of accurate records in incident reporting and safeguarding, including recording concerns objectively, escalating appropriately and maintaining an accurate account of actions taken.
Quality Assurance, Audits, and Record Retention
Explores how audits, quality checks and record retention processes can support compliance, identify gaps and improve the quality of care documentation.
Professional Standards, Communication, and Continuous Improvement
Brings together professional record keeping standards and explores how effective documentation and communication can support learning, accountability and continuous improvement.
Who Is This Course For?
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Care Workers
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Healthcare Assistants (HCAs)
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Support Workers
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Senior Carers
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Nurses
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Residential & Nursing Home Staff
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Domiciliary Care Staff
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Supported Living Staff
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Agency Care Professionals
Meet the Expert Behind Your Course
Manu Thomas is an Advanced Clinical Practitioner, Former CQC Specialist Advisor and NHS Clinical Entrepreneur Programme Fellow. As the Founder of Pentafold Ltd and CareLearner, and a member of a NICE professional committee, he brings extensive clinical, regulatory, and healthcare innovation expertise to the development of this course.
Learning Outcomes
After completing this course, you will be able to:
Receive a CPD-accredited certificate upon successful completion
Strengthen your professional portfolio with accredited training.
Safely assess manual handling operations before providing support.
Choose appropriate techniques and equipment for different situations.
Create clearer records and understand appropriate approaches to incident and safeguarding documentation.
Understand how audits, record retention, professional standards and continuous improvement support effective record management.
FAQ
Why is record keeping important in health and social care?
Accurate records support continuity of care, communication between professionals, safeguarding, accountability and informed decision-making. They also provide evidence of the care and support provided to an individual.
What makes a good care record?
Good records should be accurate, clear, factual, relevant, timely, legible where handwritten and completed in accordance with organisational and professional requirements. Records should distinguish between facts, observations, actions and opinions where appropriate.
What information should be included in care records?
Records should contain relevant information about the person's care, support, needs, observations, decisions and actions taken, according to the individual's care plan and organisational requirements. Only information that is relevant and appropriate should be recorded.
Why is confidentiality important when keeping records?
Health and social care records can contain sensitive personal information. Maintaining confidentiality helps protect people's privacy and supports trust, while access should be limited to people who have a legitimate reason to use the information.
Can care records be kept digitally?
Yes. Digital records are widely used across health and social care. Organisations must ensure that digital systems are appropriately secured and that staff follow procedures for access, passwords, information sharing, storage and data protection.
What is the difference between factual and subjective recording?
Factual recording focuses on information that can be observed, measured or verified, while subjective information may reflect a person's reported experience or professional interpretation. Staff should clearly distinguish observations, reported information and professional assessments where appropriate.
How should an incident be recorded?
Incident records should provide a clear, factual account of what happened, including relevant observations, actions taken, people notified and any required follow-up. Staff should follow their organisation's incident reporting and safeguarding procedures.
Why are audits important for record keeping?
Audits help organisations check whether records meet expected standards, identify gaps or recurring problems and provide evidence for quality improvement. They can also support governance and regulatory compliance.
How long should health and social care records be kept?
Retention periods depend on the type of record, the organisation, applicable legislation and regulatory or professional requirements. Organisations should follow their approved records management and retention policies rather than applying one universal retention period.
Is this course CPD accredited?
Yes. This Record Keeping in Health and Social Care course is CPD accredited, demonstrating recognised continuing professional development. Upon successful completion, learners receive a CPD-accredited certificate that can be used as evidence of ongoing professional learning.
Can I complete this course on my phone?
Yes. The course is fully responsive and can be completed on desktop, tablet or mobile devices. Learn at your own pace, wherever and whenever it suits you.