Clinical record-keeping 

This course explores the role of clinical records in planning and providing effective care, including simple frameworks to support record-keeping. Through realistic clinical scenarios and practical guidance, it supports health professionals to develop clear, accurate documentation practices and understand the key principles of effective clinical communication and continuity of care.

  • 2 hours

    Estimated learning time

  • Case studies

    Practice-based scenarios

  • Certificate

    Awarded on completion

  • Pre & post questions

    Track your learning

Learning objectives


After studying this course you should be able to:

  • Describe how to document clearly and safely 
  • Outline the role of record-keeping in ensuring clear measurable outcomes for patient care 
  • Illustrate the role of records in undertaking a root-cause analysis of an incident in healthcare and the importance of a clear “audit trail” 
  • Explain a nurse’s accountability and duty of care in relation to patient care and record-keeping 
  • Outline the role of records in complaints and civil court cases 
  • Describe how to use the SOAP (Subjective, Objective, Assessment, Plan) framework to record episodes of care  
The discussion areas within each course provide an opportunity to reflect on the content, share experiences from practice, and learn from other health professionals. Taking part in discussions can help support participatory learning as part of your CPD activity.

Course author

Kerri Wright, nurse and freelance writer, author of Drug Calculation — Context for Practice published by Palgrave. Updated by Bill Whitehead, company director of healthcare educational consultancy firm Bill Whitehead Ltd and associate lecturer in nursing and leadership, University of Derby.

All Nursing Times courses are written by expert nurses and double-blind peer reviewed.

Ⓒemap. All rights reserved.

Last updated 2022
Disclaimer
Healthcare knowledge is constantly changing and we have taken reasonable care to ensure that the content included in this is accurate and up to date at the time it was created. Nursing Times courses are provided for general reference and learning purposes only: they cannot of course take account of individual circumstances and should not therefore be relied upon on their own in connection with administering medicines or providing treatment. We strongly advise users to confirm that the information provided, especially with regard to drug usage, complies with all current legislation and standards of practice. By proceeding to access this course you confirm your acceptance of, and agreement to, these terms.