Care Planning & Record Keeping

Care Planning is a non-negotiable clinical skill (NMC 2009) that all registered nurses must be competent at. Carers in residential homes who are expected to write care plans must also be competent at this skill. Everyone who documents in a patient/resident’s care records is accountable in law. Registered nurses are accountable to the NMC as well as to the law.

Documentation is the evidence used to demonstrate the standards and types of care being delivered. If documentation is not up to scratch or if aspects are omitted, then clinicians/organisations can be held to account as already mentioned, both legally and professionally.When the Care Quality Commission (CQC) carry out their regular inspections of care and residential homes they will justifiably come down hard on homes where the standards of documentation is poor. Many homes will achieve poor or adequate star ratings, and many currently face an embargo or even closure as a result of poor documentation.

Poor care planning and record keeping means that organisations are unable to defend themselves in cases of litigation, as it is this documentation that is examined in court. In many cases of litigation, the Claimant has/will win compensation amounting to thousands of pounds because documentation was/is not up to acceptable standards.Nurses are frequently struck off the NMC register for poor record keeping and carers expected to write care plans are increasingly held to account for their record keeping, resulting in litigious action against them and/or their employers. GNCS will teach you and your staff on the art and clinical skill of care planning and record keeping in order to help prevent litigation against them and your organisation. The course teaches the systematic approach of assessment, re-assessment, care planning and evaluation. It looks at the activities of daily living and the use of commonly used assessment tools.

This course is based in Birmingham