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Good record-keeping is a crucial component of therapeutic practice and serves many important functions. Records benefit clients by documenting their treatment plans, the services they have received, and their progress. They help practitioners to plan and implement treatment and to monitor whether treatment is working. Additionally, accurate records help to protect practitioners in the event of legal or ethical proceedings.This module examines what information is kept and how it is recorded. It also considers the confidential nature of this information and the measures required to keep it secure. Course Subjects 1 lesson What Records to Keep Information to be Recorded How Long to Keep Records? Security and Confidentiality of Medical or Treatment Records Golden Rules for Recording Information Paper-based and Computer-based Records What Constitutes Medical or Other Treatment Records Students obtaining 70% or more marks in the examination will be awarded the BSY Certificate of Completion.

Good record-keeping is a crucial component of therapeutic practice and serves many important functions. Records benefit clients by documenting their treatment plans, the services they have received, and their progress. They help practitioners to plan and implement treatment and to monitor whether treatment is working. Additionally, accurate records help to protect practitioners in the event of...

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