Concern: record keeping and documentation
Remediation for record-keeping and documentation concerns
Documentation concerns are among the most fixable, because your records themselves become the evidence. This page sets out the Records Pack, the rules on corrections and a simple re-audit plan.
Record keeping remediation: why it is worth doing well
Record keeping remediation is the work of fixing how you document care and showing, through your own notes over time, that the problem has gone. It is one of the most practical kinds of remediation, because the evidence is right there in the record: a re-audit of your documentation either shows improvement or it does not.
Documentation concerns usually come up in one of three ways. Sometimes poor notes are the concern itself: entries missing, illegible, undated or lacking your reasoning. Sometimes they surface during another investigation, when a panel tries to understand a clinical decision and cannot find it written down. And sometimes the concern is about integrity: a note written long after the event without saying so, an entry changed or added after a complaint, or a record that does not match what happened. That last group is treated very differently, as explained below.
This page sets out the Records Pack, six self-paced courses chosen because their outlines cover documentation standards, confidentiality, candour and recurrence prevention, together with the free remediation readiness check and the reflective statement builder.
What the standards say about records
Every UK healthcare regulator expects accurate, clear and timely records. A few examples:
- NMC. Section 10 of the Code is "Keep clear and accurate records relevant to your practice". It covers completing records at the time or as soon as possible afterwards, identifying risks, not tampering with original records, attributing entries and keeping records secure. The NMC has also published learning on record keeping from the Gosport Independent Panel's findings.
- GMC. Good medical practice (2024) expects doctors to keep clear, accurate and legible records of their work.
- Other regulators. The GDC, HCPC, GPhC, GOC, GOsC and GCC each set equivalent documentation standards for their registrants. The Documentation course walks through them side by side.
Records are also governed by law and national standards beyond the regulators, including UK GDPR and the Data Protection Act 2018, CQC Regulation 17 in England, and the Records Management Code of Practice. The Professionalism in Documentation course explains how these fit together.
Recommended bundle
The courses below address this concern together. Add them to your basket in one step.
Records Pack
Documentation covers note-keeping, corrections, e-records and AI scribes; Confidentiality covers access and sharing; Duty of Candour covers honest disclosure; Similar Mistake supports re-audit and safeguards; Reflection and Insight evidence learning.
- Professionalism in Documentation for Healthcare Professionals£69 + VAT
- Ensuring Confidentiality in Healthcare Practice£69 + VAT
- Duty of Candour in Healthcare Practice£69 + VAT
- How to Ensure a Similar Mistake or Misconduct Will Not Be Repeated in Future£79 + VAT
- Reflection for Healthcare Professionals£45 + VAT
- Module on Insight for Healthcare Professionals£45 + VAT
Pack saving: 25% off these courses, plus the Reflective Practice Workbook for 12 months.
6 courses, pack price Separately £376 £282 + VAT
Poor records versus altered records
| Poor record keeping | Altered or falsified records | |
|---|---|---|
| What it looks like | Missing, brief, late, illegible or unclear entries; reasoning not recorded | Entries changed, deleted or added after the event without being marked as such; records that do not reflect what happened |
| How regulators tend to see it | A competence or practice concern, usually addressable through learning and audit | A probity concern, because it goes to honesty, and generally harder to remediate |
| Core of the remediation | Better habits, templates and a re-audit showing improvement | Insight into why it was dishonest and its effect on trust, plus the record-keeping work |
The line between them matters. A late entry that is clearly marked as late, dated and timed when written, and explains why it was added, is good practice. The same words added silently to look as though they were written earlier can become a dishonesty concern. The Documentation course covers how to correct errors and make late entries without altering the original record.
If your concern involves records that were altered or written to mislead, take legal advice and treat it as a probity matter. The Probity Remediation Pack on the bundles page is designed for that situation.
The Records Pack: six courses and what each adds
Learning time below comes from each course file. Every course ends with 15 scenario-based questions (pass mark 80%), a written reflective account and a certificate of completion issued by Healthcare Practise UK.
| Course | What it covers | Learning time |
|---|---|---|
| Professionalism in Documentation | Honesty, objectivity and accountability in records; note-keeping techniques; correcting errors; electronic records, templates and AI scribes; access, retention and security; regulator and CQC standards | About 2 hours |
| Ensuring Confidentiality in Healthcare Practice | UK GDPR and the Data Protection Act 2018, Caldicott principles, disclosure, third-party requests, electronic records and data sharing, responding to a breach | About 2 hours |
| Duty of Candour in Healthcare Practice | Being open when something goes wrong, including honest disclosure that records should support, and reporting incidents and near misses | About 2 hours |
| How to Ensure a Similar Mistake or Misconduct Will Not Be Repeated | Why errors recur, stronger safeguards, a lesson on record-keeping and communication concerns, and a personal recurrence prevention plan | About 3 hours |
| Module on Reflection | Reflective models and writing reflective notes safely and anonymously | About 2 hours |
| Module on Insight | Developing and demonstrating insight, and how regulators assess it | About 2 hours |
If your concern is narrow, for example incomplete notes in one setting, Documentation, the repetition course and Reflection may be the right core. Confidentiality matters if records were accessed, shared or stored inappropriately. The remediation pathway helps you choose.
A simple re-audit plan for your own records
For documentation concerns, a re-audit of your own records is often the single most persuasive piece of evidence. It shows the learning has reached your practice. A simple approach:
- Agree the standard. Use your employer's documentation policy and your regulator's standard. List the items each entry should contain, for example date, time, your name and role, history, findings, reasoning, plan, what the patient was told, and safety-netting.
- Measure a baseline. Ideally with a supervisor or clinical lead, review a set of your recent entries against the checklist. Record the percentage meeting each item.
- Make changes. Complete the courses, adopt a structure or template, set a personal rule about when you write notes, and agree how you will handle late entries.
- Re-audit. After a period of practice, a supervisor reviews a fresh sample of entries against the same checklist.
- Repeat. A second re-audit some months later shows the change has lasted.
Keep every audit anonymised. Your evidence portfolio should show results and examples of the format you now use, not identifiable patient records. Agree the sample size and timing with your supervisor; there is no single required number.
- Index and chronologyWhat happened and what you have done since, in date order.
- Reflective statementsYour own account of what you learned and changed.
- CertificatesCourses completed, with dates and what each covered.
- TestimonialsSigned, dated, from people who know the concerns.
- CPD logRelevant learning with notes on how you applied it.
- Action planWhat you will keep doing so it does not happen again.
Electronic records, templates and AI scribes
Many documentation concerns now involve digital tools: copy-forward text that carried old findings into a new entry, a template ticked without the examination being done, or an AI-generated note signed without being checked. The Documentation course includes a lesson on electronic records, templates and AI scribes for this reason.
The principle is the same whatever the tool: you are accountable for every entry made under your name. In your reflection, say how you now check auto-populated or AI-drafted content before signing, and how you record what you actually did rather than what the template assumes.
A practical order of work
- Take the remediation readiness check.
- If any record was altered or the concern touches honesty, get legal advice before anything else.
- Agree a baseline audit with a supervisor or clinical lead.
- Complete Professionalism in Documentation, then the repetition course and Confidentiality if relevant.
- Write your reflection with the reflective statement builder.
- Re-audit, then re-audit again later.
- Bring it together with the remediation pathway, which builds an evidence portfolio and timeline.
Prices are shown live from the course portal.
Please read: Healthcare Practise UK is an independent provider of online learning. We are not affiliated with or endorsed by any UK regulator or the NHS. Nothing on this page is legal advice, and no course, tool or score can predict or decide the outcome of a case. Panels and decision makers weigh the full picture. If you are facing a regulator process, speak to your defence organisation, union or a solicitor.
Keeping perspective
Being told your notes fell short can feel like a judgement on your whole practice, particularly if you were working under heavy pressure when the entries were made. It is worth remembering that documentation is one of the most common weaknesses found in complaints and investigations, and one of the most improvable. Talk to your defence organisation or union about support, and consider confidential services such as NHS Practitioner Health if you are eligible. If you are in crisis, contact your GP, NHS 111 or the Samaritans on 116 123.
Frequently asked questions
Can poor record keeping be remediated?
Usually yes. Poor documentation is generally treated as a practice concern that can be addressed through learning, new habits and a re-audit showing improvement. Altered or falsified records are different and are treated as a probity concern.
Can I add to a record after the event?
A late entry can be appropriate if it is clearly marked as late, dated and timed when written, and does not alter the original. The Documentation course explains how. Never change or backdate an existing entry, especially after a complaint.
Is a course enough for a record-keeping concern?
Courses alone are not enough. They give you knowledge and a certificate. A re-audit of your own records, supervised feedback and honest reflection are what show the change has reached your practice.
How long does the Records Pack take?
The course files state about 2 hours for five of the courses and about 3 hours for the repetition course, roughly 13 hours in total, plus time for reflection and re-audit.
Can I include real records in my portfolio?
Do not include identifiable patient information. Use anonymised audit results and blank or anonymised examples of the format you now use. The reflective statement builder checks for identifying details.
Are these courses approved by my regulator?
No. Healthcare Practise UK is an independent provider, not affiliated with any UK regulator or the NHS. The courses support the learning and reflection that regulators' guidance asks for.
My notes were fine but the template was the problem. What should I do?
Describe the system issue honestly and what you did to raise it, but also show what you personally now check before signing. Panels respond well to reflection that combines system awareness with personal accountability.
Not sure where to start?
Tell us your regulator and the concern. The pathway shows the courses that fit, helps you write your reflection and puts your evidence in order. It is free and nothing leaves your browser.