Communication and Record Keeping Training Course

Record keeping in care is the documenting of information relating to an individual in care. The minimum requirements of completing care records are:

• ○ Personal details of the person in question
• ○ Dates and times of key events such as arrival, departure and any important incidents
• ○ What care was given to the patient and by whom
• ○ The outcome of the care provided
• ○ A review of the care that was given
• ○ A discharge summary or details of ongoing care

Effective communication in health and social care is important because it helps build good relationships with patients, visitors and colleagues. It also helps deliver high-quality, person-centred care. Some methods that contribute to effective communication are:

• ○ Positive body language – positive body language shows that you are ready to listen to the patient. Sit where you can be seen and not half turned away.
• ○ Active Listening – Actually listen to what is being said and how it is being said. Do not jump to conclusions and allow the individual to express themselves.
• ○ Account for barriers – take into account barriers to communication such as environmental, personal. Transmission and comprehension barriers