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Care Planning and Record Keeping Certificate – Level 5
The Care Planning and Record Keeping Certificate – Level 5 equips learners with essential skills in care planning, safeguarding, medical coding, and record keeping to ensure quality care and compliance in health and social care settings.
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Learning Outcome
- Understand your role and responsibilities in health and social care and work within agreed guidelines.
- Develop skills in personal development, measuring performance, and responding to feedback to improve care.
- Implement person-centred care practices and ensure privacy and dignity for individuals.
- Learn how to communicate effectively with patients
and overcome communication barriers.
- Gain a comprehensive understanding of safeguarding practices for both children and adults.
- Master medical coding and billing, including the use of
ICD-10 and SNOMED CT systems. - Ensure infection prevention and control in care settings to
maintain a safe environment.
Course Overview
The Care Planning and Record Keeping Certificate – Level 5 course is a comprehensive program designed for healthcare professionals seeking to improve their skills in care planning, record keeping, and information management within health and social care settings. This course emphasizes the importance of effective care planning and accurate documentation to ensure quality patient care and regulatory compliance. It is ideal for care managers, healthcare assistants, social workers, and others involved in providing direct care.
The course begins with an introduction to your role in health and social care, emphasizing the importance of working in agreed ways and establishing clear roles and responsibilities in the care sector. The working in partnership module discusses collaboration with other healthcare professionals, patients, and families to ensure the highest standard of care.
In personal development, the course explores how continuous improvement and feedback contribute to enhanced care provision, while measuring performance helps identify areas for growth and better outcomes. The module on duty of care explains the ethical and legal responsibilities of healthcare professionals in protecting the rights and welfare of service users.
The course also delves into the principles of person-centred care, which empowers individuals to take control of their care decisions. You will learn effective communication strategies for addressing patient discomfort and distress and overcoming common communication barriers in healthcare settings.
Other essential topics covered include privacy and dignity in care, the importance of fluids and nutrition, and how to support mental health, dementia, and learning disabilities in a compassionate and respectful manner. Safeguarding is covered thoroughly, addressing both adult and child protection concerns, while basic life support and health and safety measures are integral to ensuring a safe care environment.
The course includes practical training in handling information, infection prevention and control, and the use of medical coding systems like SNOMED CT and ICD-10 coding for accurate clinical documentation. Medical billing processes, including the understanding of insurance plans and the handling of billing and coding errors, are explored to help learners navigate the complexities of healthcare administration.
By the end of the course, you will have the skills necessary to provide high-quality care, manage records effectively, and comply with health and safety standards in any healthcare setting.
Who This Course Is For:
- Care managers and healthcare administrators
- Healthcare assistants and support workers
- Social workers and case managers
- Care coordinators in social services or healthcare
- Individuals looking to develop a career in medical billing or coding
- Nursing professionals and allied health workers
- Medical records specialists and data analysts
- Aspiring professionals in health and social care settings
Requirements:
- No prior experience in care planning or record keeping is required.
- Basic understanding of healthcare or administration is helpful but not mandatory.
- A willingness to engage with new concepts in healthcare documentation and care practices.
Course Instructor
Learndrive Courses
Learndrive is a UK-based online learning provider committed to delivering high-quality, industry-relevant training designed to support learners in achieving their academic, professional, and personal development goals. With a growing catalogue of courses spanning compliance, business, healthcare, finance, safety, and more, Learndrive ensures that its content remains current, practical, and aligned with market demand.
What sets Learndrive apart is its learner-centric approach to education. Each course is carefully designed to promote deep understanding and long-term retention without cognitive overload. Courses feature interactive video and audio modules grounded in sound instructional design principles and backed by evidence-based learning methodologies.
Behind Learndrive is a team of seasoned instructional designers with extensive expertise in curriculum development, lesson planning, and eLearning. Their mission is not merely to deliver content, but to craft an engaging and effective learning experience that transforms knowledge into applied skills.
Whether you’re upskilling individually, training a team, or pursuing professional development, Learndrive offers accessible, flexible, and expertly designed courses to help you achieve meaningful progress.
Accreditation
This Care Planning and Record Keeping Certificate – Level 5 is accredited by CPDQE, ensuring it meets the highest professional standards. The CPDQE accreditation affirms that the course content is aligned with current industry practices and regulations. Upon completion, learners will possess the necessary skills to manage care plans, maintain accurate records, and navigate medical coding and billing systems efficiently. This certification enhances professional credibility and opens career opportunities in the healthcare and social care industries.
What Students say about us
The courses on the website are well designed, very clear and you can learn a lot of useful skills from them. A very
Enjoying the course at my pace, repeating what I did not understand and learning
Frequently Asked Questions
Everything you need to now about he product billing.
Care planning is the process of assessing an individual’s needs, setting goals, and deciding on the support or interventions required to improve their health and wellbeing.
Assessment, goal setting, planning, implementation, and evaluation. Each stage ensures that care is personalised and effective.
Assess needs, identify goals, plan interventions, and review outcomes to ensure continuous improvement in care.
Standard care plans, personalised care plans, emergency care plans, and multidisciplinary care plans, depending on the setting and patient needs.
It means organising and coordinating a person’s care to meet their physical, emotional, and social needs safely and effectively.
Individual care plans, group care plans, and specialised care plans such as palliative or rehabilitation plans.
Personal details, assessment of needs, planned interventions, goals and outcomes, and review schedule.
Professionals, and sometimes the individual and family, discuss needs, set goals, allocate responsibilities, and agree on a care plan.
Assessment, goals, interventions, responsibilities, and evaluation to monitor progress and update care as needed.
Assess needs, set objectives, design interventions, implement care, and review effectiveness to ensure quality outcomes.
Identify needs, set goals, create interventions, implement the plan, and evaluate results for adjustments.
Collect data, analyse outcomes, compare with goals, identify improvements, and update the care plan accordingly.
Course Curriculum
| Course Lecture | |||
| Standard 01: Understanding Your Role in Health and Social Care – Part 1 | 00:11:00 | ||
| Standard 01: The Importance of Working in Agreed Ways of Working in the Care Sector – Part 2 | 00:06:00 | ||
| Standard 01: Working in Partnership in Health and Social Care – Part 3 | 00:10:00 | ||
| Standard 02: Personal Development in Healthcare – Part 1 | 00:06:00 | ||
| Standard 02: Harnessing Feedback and Measuring Performance – Part 2 | 00:06:00 | ||
| Standard 03: Understanding Duty of Care in Health and Social Care | 00:06:00 | ||
| Standard 04: Promoting Equality and Respecting Diversity | 00:09:00 | ||
| Standard 05: Person-Centred Care_ Empowering Individuals in Health and Social Care – Part 1 | 00:07:00 | ||
| Standard 05: Effective Communication for Addressing Discomfort and Distress – Part 2 | 00:07:00 | ||
| Standard 06: Effective Communication in Healthcare – Part 1 | 00:06:00 | ||
| Standard 06: Understanding and Overcoming Communication Barriers_ A Guide for Healthcare Professionals – Part 2 | 00:06:00 | ||
| Standard 07: Privacy and Dignity in Care_ Guidelines for Care Workers | 00:11:00 | ||
| Standard 08: Fluids and Nutrition_ Importance and Support | 00:09:00 | ||
| Standard 09: Awareness of Mental Health, Dementia, and Learning Disability | 00:22:00 | ||
| Standard 10: Safeguarding Adults | 00:18:00 | ||
| Standard 11: Safeguarding Children | 00:10:00 | ||
| Standard 12: Basic Life Support | 00:13:00 | ||
| Standard 13: Health and Safety | 00:26:00 | ||
| Standard 14: Handling Information | 00:10:00 | ||
| Standard 16: Infection Prevention and Control | 00:11:00 | ||
| Introduction to Medical Coding | 00:09:00 | ||
| Medical Records and Terminologies | 00:09:00 | ||
| Introduction to SNOMED CT | 00:09:00 | ||
| Introduction to ICD-10 Coding | 00:09:00 | ||
| General Coding Standards of ICD-10 | 00:12:00 | ||
| ICD-10 5th Edition Codes (Chapters 1 to 4) | 00:15:00 | ||
| ICD-10 5th Edition Codes (Chapters 5 to 10) | 00:15:00 | ||
| ICD-10 5th Edition Codes (Chapters 11 to 15) | 00:14:00 | ||
| ICD-10 5th Edition Codes (Chapters 16 to 22) | 00:13:00 | ||
| Introduction to Medical Billing | 00:10:00 | ||
| Insurance Plans | 00:10:00 | ||
| Billing and Coding Errors | 00:10:00 | ||
| Medical Billing Software Programmes and Systems | 00:08:00 | ||
| Final Quiz: Care Planning and Record Keeping Certificate – Level 5 | |||
| Final Quiz: Care Planning and Record Keeping Certificate – Level 5 | 00:10:00 | ||
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