Defensible Documentation

This training is designed to offer learners an awareness in the principles of good communication and record keeping within a care environment, to ensure effective communication skills and good practice when recording information. The CQC look to this as a key indicator of a good practice in care homes

Target Group

  • People working in care homes, hospitals, community teams, domiciliary agencies and Independent and Voluntary Organisations

Learning Objectives

  • Raise awareness of importance of keeping accurate and defensible written electronic and paper records.
  • Understand the purpose and principles behind quality written information.
  • Recognise information that is appropriate for recording.
  • Identify effective and appropriate ways of presenting information.
  • Understand the need for, and limits of, confidentiality.

Course Content

This course consists of the following topics:

  • Written records for health, social and independent care.
  • Good practice guidelines.
  • What should be documented.
  • Making accurate records.
  • The use of 'plain English' and minimising the use of jargon.
  • Keeping records secure.
  • Confidentiality and data protection.
  • Principles of the data protection act.
  • Defensible documentation.
  • The potential consequences of poor record keeping.

Training Level

  • Adaptable to needs


  • Please contact


  • 1 Day

Book Course


Everything was useful especially understanding the difference between fact and opinion when writing your daily notes.
I found the training very educational and interesting.
Very clear and concise good style of presentation, relaxed and interesting.