The Chartered Society of Physiotherapy The Chartered Society of Physiotherapy


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Competence in record keeping

File 139761It is your responsibility to develop and maintain competence in record keeping.

The publication ‘Learning to manage health information’ provides a framework that consolidates learning outcomes in health informatics, which should be embedded into all health professional education programmes.

The framework covers the following aspects:

  • Protection of Individuals & Organisations
  • Data, Information & Knowledge
  • Communication & Information Transfer
  • Health & Care Records
  • The Language of Health: Clinical Coding & Terminology
  • Clinical Systems & Applications
  • eHealth: the Future Direction of Clinical Care
  • Essential information technology skills needed to support the other themes.

Maintaining competence in record keeping

As poor record keeping poses a significant clinical safety risk, it is paramount that staff are supported to maintain their competence in this area.

Individual training needs in relation to record keeping should be discussed and prioritised through line management support and the appraisal process.

Such training may encompass improved understanding around the legal and regulatory framework within which physiotherapy staff work, through to how to input data into an electronic clinical information system, a mobile networked tablet device, or a personal digital assistant (PDA).

The national IT programmes in the four UK countries offer support around information governance training.

Courses or online training modules usually cover topics such as access to health records, confidentiality etc.

Employers may also offer information governance training tailored to increase understanding of local procedures.


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