Key Information

• Dates: According to each scheduled training programme
• Duration: 10 training hours (2 days)
• Delivery Mode: Live online participation
• Certification: Certificate of Attendance

Programme Description

The quality and completeness of clinical documentation are fundamental to the safe and effective delivery of healthcare services. The patient medical record is not merely a repository of clinical information; it serves as a critical communication tool among healthcare professionals, provides legal and clinical documentation of the care delivered, and supports informed clinical decision-making.

This programme introduces participants to the principles of effective patient record management, the quality and information security requirements governing clinical documentation, and methodologies for assessing the completeness, accuracy, and compliance of patient records through Medical Audit and Clinical Documentation Review methodologies.

Added Value for Participants

Participants will acquire practical knowledge and skills to improve the quality of clinical documentation, reduce risks associated with incomplete or inaccurate medical records, and apply structured audit and evaluation tools to enhance patient record management and healthcare quality.

Training Modules

• Health Information and Medical Information

• Introduction to the Patient Medical Record

• Structure and Content of the Patient Medical Record

• Legal and Regulatory Framework

• Information Quality and Information Security

• Access Management and User Permissions

• Medical Record Storage and Retention

• Electronic Health Records (EHRs)

• Health Data Protection

• Medical Audit and Clinical Documentation Review

Learning Outcomes

Upon successful completion of the programme, participants will be able to:

• Apply best practices for the maintenance and management of patient medical records.

• Evaluate the completeness, accuracy, and quality of clinical documentation.

• Identify risks associated with incomplete or inaccurate clinical documentation.

• Utilize Medical Audit methodologies to support continuous quality improvement in healthcare services.

Target Audience

• Physicians

• Nurses

• Healthcare Professionals

• Quality Managers and Quality Officers

• Internal Auditors

• Clinical Audit and Medical Audit Professionals

• Students of Health Sciences

Expression of Interest

Complete the expression of interest form to receive information about upcoming programme dates and future training opportunities.