Record Keeping Course for Healthcare Professionals (UK)

A record keeping course for healthcare professionals covers what your regulator expects of your records and how to meet it: notes made at the time or as soon as possible afterwards, entries that are clear, accurate, attributed, dated and timed, the right way to correct an error or add a late entry, honesty in forms and reports, and keeping records secure. A good one also takes you through why records matter when a complaint or investigation is opened, and how to show remediation in a written response. Our Professionalism in Documentation for Healthcare Professionals course is £79 (£50 with Bulk Buy 10) for 2 CPD hours, online and self-paced, with a dated certificate, and Probity & Ethics is CPD certified by The CPD Certification Service.

Facing a concern about your records?

A complaint, an employer investigation or a referral to your regulator has turned on what was or was not written down, an entry made later, or a form or report. You need evidence of insight and of the steps you have taken, before a decision is made.

Looking for record keeping CPD?

You want learning on documentation and your regulator's standard to record for appraisal, revalidation or renewal, with a certificate and material for a reflection. This guide covers both.

In short

Every UK healthcare regulator sets a records standard: Good medical practice paragraphs 69 to 71, standard 10 of the NMC Code, standard 4.1 of the GDC Standards for the Dental Team and standard 10 of the HCPC standards of conduct, performance and ethics.
A record keeping course should cover timing, accuracy, attribution, corrections and late entries, honesty in forms and reports, confidentiality and security, and records as evidence.
After a concern, a course is one step. The NMC's guidance says decision makers look at whether the steps taken are relevant, measurable and effective.
The same course is CPD: record it with the date, the hours and how it relates to your practice.

What a good record keeping course covers

Records are the part of practice a concern is tested against. When a patient, an employer or a regulator asks what happened, the first thing read is what you wrote at the time. A course on record keeping should take each part of the standard in turn and link it to the wording your regulator uses.

Area	What the course should cover
Timing	Making records at the time or as soon as possible afterwards, and recording when a note was written later.
Content	Clinical findings, the treatment or medicine proposed or given, the information shared with the patient, the patient's concerns and preferences, consent, and decisions made, including a decision to take no action.
Clarity and attribution	Entries that are clear, legible, dated, timed and attributed to you, without unnecessary abbreviations, jargon or speculation.
Corrections and late entries	How to correct an error or add a late entry so the change is visible and dated, and where a change becomes a question of honesty.
Forms and reports	Honesty and accuracy in references, reports, insurance and employment forms and other non-clinical documents.
Confidentiality and security	Keeping records secure and in line with data protection law.
Records as evidence	Why records decide what a complaint or investigation can show, and how to evidence that your record keeping has changed.

If the concern is about honesty in a document rather than the quality of your notes, a probity course may fit better. Our page Which course do I need? matches each kind of concern to a course.

What your regulator says about records

Each UK regulator writes its own records standard. The wording differs, but the expectations are close: records made at the time, complete, clear, accurate and kept securely.

"You must make sure that formal records of your work (including patients' records) are clear, accurate, contemporaneous and legible."

GMC, Good medical practice 2024, paragraph 69

Regulator	Standard	What it says
GMC	Good medical practice, Domain 3, paragraphs 69 to 71	Records must be "clear, accurate, contemporaneous and legible". The GMC defines contemporaneous as "making records at the same time as the events you are recording, or as soon as possible afterwards". Paragraph 70 lists what patients' records should include, among them decisions made and actions agreed, "including decisions to take no action", and "who is creating the record and when". Paragraph 71 covers keeping records securely.
NMC	The Code, standard 10: "Keep clear and accurate records relevant to your practice"	10.1: "complete all records at the time or as soon as possible after an event, recording if the notes are written some time after the event". 10.3: "complete all records accurately and without any falsification". 10.4: attribute your entries to yourself, "clearly written, dated and timed". 10.5: keep records securely.
GDC	Standards for the Dental Team, standard 4.1: "You must make and keep contemporaneous, complete and accurate patient records"	Guidance 4.1.1 asks for an up-to-date medical history each time you treat a patient, and lists radiographs, consent forms, photographs and referral letters as part of the record. 4.1.5: amendments must be "clearly marked up and dated". 4.1.4: record the name or initials of the treating clinician.
HCPC	Standards of conduct, performance and ethics, standard 10: "Keep records of your work"	10.1: "full, clear and accurate records for everyone you care for, treat or provide other services to". 10.2: complete records "promptly and as soon as possible after providing care". 10.3: protect records "from loss, damage or inappropriate access".

The GPhC, GOC, GCC, GOsC and Social Work England each publish their own standards that include records too. For nurses and midwives, our guide to NMC record keeping takes standard 10 in detail, and record keeping in healthcare covers the principles across the professions.

When you need one: after a complaint or investigation

A record keeping course is the course people look for when a concern turns on what was written, or not written. The concerns it speaks to include:

Your notes have been criticisedA complaint or an employer investigation says your notes were incomplete, unclear or missing, and you need to respond to the record rather than to your memory of the day.
An entry was made or changed laterSomething was added, corrected or completed after the event, and the question now is whether it was done openly, dated and marked as a later entry.
A form or report is in questionA reference, an insurance or employment form or a report contained something inaccurate. These are probity concerns as well as records concerns.
Consent or a discussion was not recordedA patient says they were not told about a risk or an option, and your notes do not show the conversation.
Records were not kept securelyNotes were lost, shared with the wrong person or accessed without a reason.

Before you start, take advice. Your defence body, union or indemnity provider can tell you what to send and when. Do not alter a record after a concern has been raised; if a record needs a later note, it must be a dated addition that is marked as such. A course you complete before you reply lets you describe what you have already done, not what you plan to do.

How a course is looked at once a concern has been raised

The NMC publishes a statement of how decision makers look at the steps a registrant has taken. Its fitness to practise guidance, "Has the concern been addressed?", says the steps should be:

relevant, "directly linked to the nature of the concerns";
measurable: where a course has been completed, "information should be provided to help the decision maker understand the scope of the course, the topics covered and the results of any assessments"; and
effective, "clearly demonstrating that past failings have been objectively understood, appreciated and tackled".

The same guidance says reflective work carries more weight where the registrant can "give examples not only of what they have learned following the concerns being raised, but also how they have applied this learning in their practice". For a records concern, that means showing your notes now: an audit of your own recent records against your regulator's standard, set beside the certificate and your reflection.

What a course does not do

A course does not decide the outcome of a case, and no course can promise one. Choose a course on the subject of the concern, keep the certificate, the course outline and the assessment result together, and write a reflection with examples from your own practice.

Reflection and insight

If you have been asked to show insight, our Module on Reflection and Module on Insight (£49 each, 1.5 CPD hours) take you through writing a reflection after a concern.

Using a record keeping course for CPD

You do not need a concern to take a record keeping course. Each regulator sets its own CPD, appraisal or revalidation rules, and learning on records is relevant to every register. For CPD, record:

What you did: online course, self-paced.
When: the date on your certificate.
Hours: the CPD hours on your certificate (2 for our record keeping course).
Why it is relevant: the standard it relates to, for example paragraph 69 of Good medical practice, standard 10 of the NMC Code or standard 4.1 of the GDC standards.
What changed: a short reflection on what you now do differently in your notes.

Nurses and midwives can read our guide to CPD courses for nurses in the UK for how an online course counts towards NMC revalidation.

Our record keeping course

Online course

Professionalism in Documentation for Healthcare Professionals

Self-paced and online, with instant access and a certificate on completion recording the course title, CPD hours and date. Written for UK healthcare professionals facing a complaint, allegation or investigation about their records, notes, forms or reports, and for those adding record keeping to their CPD. Probity & Ethics is CPD accredited by The CPD Certification Service.

£79 (£50 with Bulk Buy 10)
2 CPD hours
8 sections
Certificate on completion

Professionalism in documentation
Key principles
Best practice in clinical documentation, including correcting errors and late entries
Integrity in non-clinical documentation
Documentation in regulatory processes
What the regulators set out
Breaches and remediation
Conclusions and assessment

View the record keeping course → Any 10 courses for £500

Courses that work alongside it

See every course for your register:

Frequently asked questions

What does a record keeping course for healthcare professionals cover?

It covers what your regulator expects of your records: notes made at the time or as soon as possible afterwards, entries that are clear, accurate, attributed, dated and timed, how to correct an error or add a late entry, honesty in forms and reports, and keeping records secure. It also covers why records matter in a complaint or investigation and how to show remediation. Our course has 8 sections and ends with an assessment.

When do I need a record keeping course?

Two situations bring people to one. The first is a complaint, an employer investigation, a regulator referral or a hearing that turns on your notes, a later entry, or a form or report. The second is CPD: you want learning on documentation and your regulator's records standard to record for appraisal, revalidation or renewal.

What do the UK regulators say about record keeping?

The GMC says formal records of your work must be clear, accurate, contemporaneous and legible (Good medical practice, paragraph 69). The NMC Code, standard 10, asks nurses and midwives to keep clear and accurate records, written at the time or as soon as possible afterwards and without falsification. The GDC's standard 4.1 asks for contemporaneous, complete and accurate patient records, and the HCPC's standard 10 asks for full, clear and accurate records.

Will a record keeping course help with a fitness to practise concern?

A course is one step, not an outcome. The NMC's guidance says decision makers look at whether the steps you have taken are relevant, measurable and effective, and gives more weight to reflection that shows how you have applied the learning in practice. For a records concern, keep the certificate, the course outline, an audit of your recent notes and your reflection together, and take advice from your defence body, union or indemnity provider.

Can I use a record keeping course for CPD?

Yes. Learning on records and your regulator's standard is relevant to every register, and you can record it for appraisal, revalidation or renewal with a reflection on what you now do differently. Record the date, the CPD hours on your certificate and the standard the course relates to.

Is the record keeping course CPD certified?

Probity and Ethics is CPD certified by The CPD Certification Service. The Professionalism in Documentation for Healthcare Professionals course is £79 (£50 with Bulk Buy 10) for 2 CPD hours, self-paced and online, with a dated certificate on completion.

Sources

This guide is based on the following regulators' pages, checked on 24 October 2026.

Record Keeping Course for Healthcare Professionals: What a Good One Covers