This course explains what good clinical documentation looks like, why record-keeping concerns arise, and why altering or falsifying a record is treated as a question of honesty rather than competence. It shows you how to write contemporaneous notes and late entries correctly, how to respond if a concern has been raised about your records, and how to build a reflection and remediation plan with evidence that others can verify.
What you will learn
- Describe the features of a clear, accurate, contemporaneous and attributable clinical record.
- Write a correctly labelled late entry and correct an error in a paper or electronic record without obscuring the original.
- Distinguish between poor record keeping, which is a competence concern, and altering or falsifying records, which is a probity concern.
- Explain how regulators use the clinical record in an investigation and what they mean by insight and remediation in record-keeping cases.
- Write a structured reflection and a remediation plan with specific, verifiable and sustained evidence.
Course content
- Why records matter (3 min)
- What a good record looks like (4 min)
- Late entries, corrections and electronic records (4 min)
- Why record-keeping concerns arise (2 min)
- When records become a question of honesty (2 min)
- What regulators expect: insight and remediation (2 min)
- Case study: a weak and a strong reflection (3 min)
- Building your remediation plan (2 min)
- Knowledge check (10 questions, 10 min)
- Guided reflection (15 min)
Standards and guidance covered
- NMC: The Code (2015, updated 2018), section 10 on keeping clear and accurate records, and the sections on honesty and openness
- GMC: Good Medical Practice (2024), including the duties to keep clear, accurate and legible records and to act with honesty and integrity
- HCPC: Standards of conduct, performance and ethics (2024), including the standard on keeping records of your work
- GPhC: Standards for pharmacy professionals (2017), including communicating effectively, using professional judgement and behaving in a professional manner
- UK GDPR and the Data Protection Act 2018, and the Records Management Code of Practice for health and social care
Certificate
Courses are free to study. When you pass the knowledge check (80%) and complete your reflection, you can buy a verified certificate showing your CPD time, with a unique ID and QR code that anyone can check on our verification page.
Study free at your own pace on any device.
Related guides
How to Build a Remediation Plan That Shows Real Change
How to build a remediation plan as a nurse, doctor or AHP: set specific goals, choose relevant training, get supervised evidence and show real change.
Probity and Dishonesty: Why Regulators Treat It So Seriously
Why the GMC, NMC and HCPC treat dishonesty so seriously, what makes a probity case worse or less serious, and how to respond to a dishonesty concern.
Record Keeping Mistakes That Lead to Complaints and Referrals
The record keeping mistakes that most often lead to complaints and regulator referrals for nurses and doctors, and how to write safer clinical notes.
Practitioner Insight is an independent education provider. It is not affiliated with or endorsed by the GMC, MPTS, NMC, HCPC, GPhC or any NHS organisation, and this information is not legal advice. If you have been referred to a regulator, speak to your defence organisation, trade union or legal representative.