Defensible Documentation Training

Defensible documentation training is delivered by live interactive webinar and onsite to groups of up to fifteen delegates. It is designed to give attendees a better understanding of the principles of good communication and record keeping. Effective communication skills are essential when working in the healthcare sector.  The CQC look to this as a key indicator of a good practice.

Target Group

Defensible Documentation Training is targeted at managers, nurses, team leaders, HCA’s and support workers who work in hospitals, care homes, community teams, mental health units, learning disability units, domiciliary agencies and voluntary organisations.

Learning Objectives

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

Course Content

This training consists of the following topics:

• Why do we need defensible documentation training?
• Written records for healthcare and independent care.
• Good practice guidelines.
• What should and should not be documented.
• Taking and making accurate records.
• The use of ‘plain English’ and minimising the use of jargon.
• Keeping records secure.
• Confidentiality and GDPR.
• Principles of the GDPR.
• Defensible documentation.
• Legalities
• The potential consequences of poor record keeping.

Defensible Documentation Training Assessment and Certification

Assessment is carried out by the trainer throughout the course.

On successful completion of the course students will receive a certificate of attendance which is valid for three years.

FAQ’s

1. Who is the Defensible Documentation Training suitable for?
This course is designed for healthcare professionals including managers, nurses, team leaders, healthcare assistants (HCAs), and support workers across a wide range of settings—such as hospitals, residential care homes, domiciliary agencies, mental health units, and voluntary organisations.

2. How is the Defensible Documentation Training delivered?
Training is delivered either onsite or via a live, interactive webinar. It’s highly engaging and tailored for groups of up to fifteen delegates to ensure maximum interaction and learning.

3. What does “defensible documentation” mean in a healthcare setting?
Defensible documentation refers to clear, accurate, and objective record keeping that stands up to scrutiny. It protects both the individual and the organisation by demonstrating accountability, sound decision-making, and compliance with legal and regulatory frameworks.

4. What topics are covered in the course?
The course explores the essentials of effective record keeping, including legal considerations, confidentiality and GDPR, plain English writing, what to include (and what to avoid) in documentation, and the risks associated with poor record keeping.

5. Will I receive a certificate after completing the training?
Yes. All delegates who complete the course will receive a certificate of attendance, valid for three years, demonstrating their understanding of quality documentation practices in line with sector expectations.

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