Medical Record Keeping and Documentation Course for UAE Clinicians
Medical Liability Committees read your notes before anything else. Learn to write entries, late entries, reports and certificates that are accurate, defensible and lawful.
2learning hours
20final questions
80%pass mark
PDFcertificate
What you will learn
Explain the clinical, legal and regulatory purposes of the medical record in the UAE and why Medical Liability Committees rely on it.
Identify the federal documentation duties in Federal Decree-Law No. (4) of 2016, Cabinet Resolution No. (40) of 2019 and Federal Law No. (2) of 2019, and the standards of your own licensing authority.
Write clinical entries that record history, findings, reasoning, plan, communication and safety-netting in clear, objective and respectful language.
Document consent, refusal, discharge against advice, opposite-gender examinations and telehealth encounters in line with federal law and DHA or DOH requirements.
Make correctly labelled late entries and correct errors on paper and electronic records without altering or deleting the original.
Use EMR templates, copy-forward, shared records (Malaffi, NABIDH, Riayati) and dictation or AI tools safely and within data-localisation rules.
Apply the 25-year federal retention floor and respond correctly to patients' requests for access to or changes in their records.
Write medical reports and sick-leave certificates that are accurate, within scope and consistent with the record.
Protect the integrity of the record after a complaint or incident and describe how committees and licensing authorities respond to documentation concerns.
Plan and evidence measurable improvement in your own documentation through audit, reflection and supervision.
Relevant to
The UAE codes, standards and laws this course helps you reflect on. Relevance is our own mapping; it is not an approval by any authority.
DHADHA Code of Ethics ST-66 sections 9 and 10, including the ban on altering records, and Standards 5 and 6; DHA Guidelines for Managing Health Records (2019)
DOHDOH Patient Consent Standard (2025), ADHICS V2 (2024), Malaffi policy and Incident Reporting and Management Standard V2
MOHAPDocumentation duties in Federal Law No. 5 of 2019 and Federal Law No. 6 of 2023; Riayati shared records
Federal Decree-Law No. 4 of 2016 and Cabinet Resolution No. 40 of 2019; Federal Law No. 2 of 2019 (Arts 4, 13, 16, 20)
About this course
This course explains how to keep medical records that are accurate, honest and defensible in UAE practice. It covers the documentation duties in Federal Decree-Law No. (4) of 2016 on Medical Liability and its Executive Regulations (Cabinet Resolution No. 40 of 2019), the 25-year retention floor in Federal Law No. (2) of 2019, the DHA Code of Ethics (ST-66) and Guidelines for Managing Health Records, Dubai Executive Council Resolution No. 49 of 2024, and DOH standards including ADHICS V2 and the Malaffi policy. It then applies them to everyday practice: what an entry should contain, objective and respectful writing, consent and refusal records, late entries, corrections, templates and copy-forward, shared records in Malaffi, NABIDH and Riayati, telehealth and AI drafting tools, medical reports, sick-leave certificates, patient access and retention.
The course is for every licensed profession that writes in a UAE patient record: physicians and dentists, nurses and midwives, pharmacists, and allied health and diagnostic staff, whether licensed by MOHAP, DHA, DOH, the Sharjah Health Authority or in Dubai Healthcare City. It is particularly useful if you have recently joined a UAE facility and are still learning its electronic record, if an audit or a colleague has questioned the quality of your notes, or if a complaint has made you look again at what your records actually show.
In UAE complaints, the file often decides the outcome. Medical Liability Committees work from the original medical record, licensing authorities treat altered entries and false sick leave as serious violations, and recent enforcement has included precautionary suspensions and referral to the Public Prosecution for record manipulation and certificates issued without examination. Each section pairs the legal duty with worked UAE cases from Fujairah to Abu Dhabi, and the course adds checklists to use on your own notes, a guide to protecting the record once a complaint arrives, and a reflective account template.
Syllabus
11 sections, about 2 learning hours, 20-question final assessment
1The medical record in UAE practice2 lessons
Why the medical record matters in UAE practice
The UAE legal and regulatory framework for medical records
2What a good record contains3 lessons
The content of a clinical entry
Writing clearly, objectively and respectfully
Recording communication, consent, refusal and decisions
3Timing, late entries and corrections2 lessons
Contemporaneous records and legitimate late entries
Correcting errors without altering the record
4Electronic records, shared records and digital tools3 lessons
Working safely in the electronic medical record
Templates, defaults and auto-populated text
Shared records, telehealth, messaging and AI tools
5Access, transfer and retention of records2 lessons
Patients' access to their records and transfers of care
Retention, storage, security and disposal
6Medical reports, certificates and sick leave2 lessons
Medical reports and certificates
Sick-leave certificates
7Records in complaints, committees and investigations3 lessons
Who reads your records when something goes wrong
Your records after a complaint, incident or notice
Documentation failings that reviewers commonly find
8When documentation falls short: penalties, insight and remediation2 lessons
How licensing authorities respond to documentation concerns
Showing insight and remediating documentation
9Conclusion and key points1 lesson
Conclusion and key points
10References and further reading1 lesson
References and further reading
11Your reflective account1 lesson
Your reflective account
Course facts
CPD value
Approximately 2 learning hours (self-directed CPD, including knowledge checks, reflection and assessment)
Audience
Every licensed profession that documents care in the UAE: physicians, dentists, nurses, midwives, pharmacists, and allied health and diagnostic professionals licensed by MOHAP, DHA, DOH, SHA or DHCR
Standards covered
Federal Decree-Law No. 4 of 2016 on Medical Liability (Arts 3, 4, 5, 8, 9, 18 to 23) and Cabinet Resolution No. 40 of 2019 (Arts 2, 3, 7, 10); Federal Law No. 2 of 2019 on ICT in Health Fields (Arts 4, 13, 16, 20); Federal Law No. 5 of 2019 (Arts 17, 22, 28, 29); Federal Law No. 6 of 2023 (Arts 8, 13, 14) and Cabinet Resolution No. 176 of 2025; Federal Decree-Law No. 30 of 2021 (narcotic records); Ministerial Resolution No. 14 of 2021 (Patient's Rights and Responsibilities Charter); DHA Code of Ethics ST-66 (2025); DHA Guidelines for Managing Health Records (2019); DHA Guidelines for Patient Consent GU-05; DHA Standards for Health Information Consent and Access Control (2025); NABIDH Subject of Care Rights; DHA ST-53; Dubai Executive Council Resolution No. 49 of 2024 (Schedule 4 items 34 to 36 and 59 to 62); DOH Patient Consent Standard (2025); ADHICS V2 (2024); DOH Malaffi policy; DOH Incident Reporting and Management Standard V2; Abu Dhabi Law No. 10 of 2018; Riayati
Format
Self-paced, gated lessons with knowledge checks, UAE case studies and reflection
Assessment
20 scenario-based questions, 80% to pass (16 of 20)
Outcome
Certificate of completion and a written reflection for your professional development portfolio
Alignment
Supports reflection on the record-keeping provisions of the DHA Code of Ethics ST-66 (sections 9 and 10, including the prohibition on altering records) and its standards on professional integrity and accountability (Standard 6) and privacy, confidentiality and data protection (Standard 5); the DHA Guidelines for Managing Health Records; the DOH Patient Consent Standard, ADHICS V2 and Malaffi policy; and the federal documentation duties applied by MOHAP and SHA
Price
AED 349
Who this course is for
Doctors, dentists, nurses, midwives, pharmacists and allied health professionals licensed by MOHAP, DHA, DOH, SHA or DHCR.
Written for professionals licensed by any UAE authority: MOHAP, DHA, DOH, SHA or DHCR. Where the rules differ, the course explains the difference.
Your certificate
Your name, the course title and the approximate learning hours
Completion date and your final-assessment score
A unique certificate number with a QR code anyone can verify
The certificate states that the course is not accredited by any UAE health authority and that no CME/CPD points or credits are awarded. Whether it counts towards your licence renewal is for your licensing authority to decide.
Healthcare Practise
Certificate of Completion
This certificate is presented to
Your Name
Medical Record Keeping and Documentation Course for UAE Clinicians
Approximately 2 learning hours · Final assessment score shown
Certificate No.HP-7K2M-9QXA
HPUAE
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Questions about this course
How do I correct an error in a patient record without breaking UAE rules?
Never alter, delete or overwrite the original; the DHA Code of Ethics forbids altering, falsifying or destroying records. Module 3 shows how to make a correctly labelled late entry or correction on paper and in an electronic record, so that anyone reading it later can see what changed, when and why.
Is copy-forward in an electronic record a risk?
Yes. Module 4 covers EMR templates, copy-forward, shared records such as Malaffi, NABIDH and Riayati, and dictation or AI tools. Copied text that no longer matches the patient can mislead the next clinician and weaken your account if the record is later reviewed, so the course shows safer habits.
How long must patient records be kept in the UAE?
Federal Law No. 2 of 2019 sets a floor of at least 25 years from the date of the last health procedure. Module 5 explains this retention rule, data localisation, transfer of records and how to respond correctly when patients ask to see their records or ask for something in them to be changed.
Why do Medical Liability Committees focus on the medical record?
Because it is the contemporaneous evidence of what you found, thought, did and told the patient. Module 7 explains how committees and licensing authorities use the record, and how to protect its integrity after a complaint or incident, including why a sudden edit made after a complaint can create a separate probity concern.
Will this course fix a documentation concern raised about my notes?
It can help you build measurable improvement through audit, reflection and supervision, as module 8 shows. It cannot decide any outcome, it is not accredited by any UAE health authority, and it does not replace ordered training unless the authority accepts it. Speak to your insurer or a lawyer about an open concern.
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