Patient Records and Confidentiality

Accurate notes, lawful access and the duty of confidence.

What the course covers

8 modules, 32 topics. Open any one to see what sits inside it.

1. 1.1 The record as a clinical tool
2. 1.2 The record as a legal document
3. 1.3 Who reads a record, and when
4. 1.4 What a poor record costs
1. 2.1 Contemporaneous, accurate, legible
2. 2.2 Objective description against opinion
3. 2.3 What to include, and what to leave out
4. 2.4 Signing, dating and identifying yourself
1. 3.1 Paper and electronic records
2. 3.2 The common documentation formats
3. 3.3 Charts, observations and flow sheets
4. 3.4 Templates, and the risk of copying forward
1. 4.1 The duty of confidence
2. 4.2 Sharing within the care team
3. 4.3 Sharing outside it, and when that is lawful
4. 4.4 Conversations, screens and what gets overheard
1. 5.1 Consent to share information
2. 5.2 Patients reading their own records
3. 5.3 Requests from family and third parties
4. 5.4 Children, and people who lack capacity
1. 6.1 The principles governing health data
2. 6.2 Storage, transfer and email
3. 6.3 Portable devices and remote working
4. 6.4 Retention and secure destruction
1. 7.1 Correcting an error in a record
2. 7.2 Missing, lost or altered records
3. 7.3 Breaches, and how they are reported
4. 7.4 Records in complaints and investigations
1. 8.1 Documenting under time pressure
2. 8.2 Handover documentation
3. 8.3 Auditing record quality
4. 8.4 Habits that protect both you and the patient

By the end of this course you will be able to explain and apply:

Two hours, not two months Eight short modules. Finish in a day, or do one module a night for a week.

Job-ready from the first module Everything here is a task you will actually be asked to do at work, not theory you will never use.

Built for a phone Watch on the bus, pause mid-module, pick up where you stopped. No download, no lab.

A certificate that can be checked Every certificate carries an ID your college or an employer can verify on our site.

About two hours in total — eight modules of roughly fifteen minutes. You can do it in one sitting or spread it across a week. Your place is saved either way.
No. There is no prerequisite course and no software to install. A phone, tablet or computer with an internet connection is enough.
Yes. This course is placed at Pre-degree / Foundation for India, and the content is written for that level. If you are at a different stage, change your level at the top of the page and the courses will change with it.
A certificate for the course, carrying an ID that your college or an employer can check on our verification page. You keep access to the material afterwards.
Yes — ₹450 for this course on its own, or ₹1,450 for all five in this set, which works out cheaper if you want more than one.
There is a short quiz at the end of each module so you can check what stuck. It is not timed and you can retake it.
Change your country using the picker at the top. Level names, degree names and prices all switch to that country, and the courses adjust to its education system.

Wording shown for India. Pick a different country at the top and the terms, currency and programme names change with it.