101 RECORD KEEPING

Record keeping is an integral aspect of the service and our duty of care, and is a written reflection of the type and quality of intervention. We should ensure that our recording shows a clear, accurate and up-to-date record of our contacts concerning service users.

Departmental standards for record keeping are necessary in order to provide a consistent standard of documentation across all teams and workers. The standards for record keeping are applicable to all members of the service, including support staff, social workers, social care coordinators and management. 

101.1 Why we keep records:

  • to ensure a comprehensive and accurate record of the service user’s needs, the objectives and outcomes of intervention, and the reasoning used to achieve the objectives
  • for audit and evidence-based practice
  • to ensure accountability to service users, managers and the employer
  • to provide a systematic record of on-going intervention
  • to enable staff to provide continuity of service where the case is transferred or where the worker is unavailable
  • to act as a legal record of our actions and the service user’s interaction with the service. Records provide evidence for complaint investigations and enquiries e.g. when service users challenge a lack of or refusal of service, seek damages or in cases of professional misconduct. Failure to maintain adequate records is often regarded as misadministration by the Ombudsman.

101.2 What to record:

  • All important telephone calls, especially to the service user – successful and failed attempts
  • correspondence, including emails, received or sent
  • all visits
  • discussions in supervision regarding particular cases and key decisions made
  • professional advice
  • key documents produced
  • meetings held including panels and multi-disciplinary reviews
  • all reports that relate to the service user
  • mandatory fields within the electronic record, including the offer of a carer’s assessment, and direct payments: you must complete mandatory fields.

101.3 What to include in records:

  • date and time all assessments or contacts were carried out
  • the type of contact i.e. telephone call, visit
  • the consent of the service user to be assessed by a worker and how this was given i.e. verbal, written, or by a next of kin, including when consent is refused or withdrawn
  • a detailed note of what was said when conveying information to other agencies – do not generalise
  • contact details for all involved with the service user e.g. carer, next of kin, doctor, professionals (to be recorded on the ASCC Network Sheet), and any contacts made with them
  • views and wishes of service users and carer: the wishes and views of the service user should be recorded and the recording should make clear any disagreements or differences in perception the service user may have
  • unmet needs
  • who was present at visits
  • as much information as possible should be collected at referral including name, telephone number, date of birth, GP and other contact details.

101.4 Basic information

It is important to keep personal information up-to-date and accurate, since this is information required by any person involved in the case. Particular things to pay attention to include:

  • checking the address of the person
  • making sure the person’s consent has been requested and what the answer was, and that this up-to-date
  • recording warnings of risk to the person or to professionals or members of the public
  • recording ethnicity in the Equalities section of the Basic Information Sheet (BIS), as this is a key performance measure of compliance with the Race Relations (Amendment) Act 2000. We need the information to monitor fairness of access and service provision.

101.5 Warnings

Warnings are strictly about the safety of staff and members of the public. They should be added to cases where there is a risk to staff members or members of the public. Warnings should not be used for any other reason.

Warnings are added via the Person Index. Once added they appear across social care systems so they will appear in ASCC and ICS – the Integrated Children’s System. The warning is also linked to the Council’s corporate warning system – In Check – so that colleagues across the Council can be alerted to concerns about a person.

In ASCC, every time a document is opened on the case the warning will appear as a window.

Warnings should reflect real and verifiable concerns and should always be backed up by evidence. A threat may be real or perceived as long as in every case they are supported by evidence.

If you wish to add a warning for a person, please speak to your manager to agree the warning. The information should be passed to a member of business support staff who will add it to PI – practitioners are not able to add warnings themselves. You will need to supply the reason for the warning – this should be evidence based e.g. “Mr X has made inappropriate remarks to members of care staff on a number of occasions; see diary sheets of 12/09/2010 and 01/03/2011. Staff should not visit alone.”

Ideally service users should be informed about warnings, but in many cases this may not be practicable. Warnings should also be reviewed at regular intervals, at least annually. If a warning changes or is no longer appropriate, please tell a member of business support staff. Warnings can be de-activated – leaving a record of it as part of the case history, if this is appropriate – or deleted completely. Please advise business support accordingly.

101.6 Record keeping standards

Records should be written with a view to the service user and, if necessary, the courts having access to the record.

  • Records should be chronological.  The notes should record a sequence of chronological events relating to the service user.
  • All recording must be professional
    Writing should be:
    - legible where paper documents are kept on file
    - professional and typed
    - factual – containing relevant information
    - clear – clearly recorded needs, actions and outcomes
    - concise and complete: consider using headings and bullet points to ensure content is concise
    - relevant and unambiguous
    - cross-referenced where appropriate to other documents or paper files.
  • All language used must be appropriate
    - Language must be professional. Please proof read all recording to ensure a good standard of English.
    - Language should be objective.  Identify subjective statements as such..
    - Avoid or keep abbreviations and jargon to a minimum as they can be ambiguous. If abbreviations are used make sure that they are clear in context or do not use if they may not be understood.
    - Be careful of terminology. Different meanings are associated with the same phrase e.g. ‘confused’ it could be anything from a misunderstanding to a severe cognitive impairment.
    - Avoid slang except where directly quoting others appropriately.
    - Record direct quotations carefully with an awareness of the impact of recording some information.
  • All recording must be clear
    - Identify source of information using names and then descriptions – e.g. service user, carer, daughter, Emergency Duty Team etc. 
    - Record whether the information is based on observation, what is reported by the service user or what is your professional judgement. Distinguish between fact and professional opinion. There is a difference between what was observed and what the assessor’s professional opinion is about what they have observed.
    - Make sure opinions refer to the evidence upon which they are based.
    - Record only relevant and significant information, not a detailed narrative of each contact. Don’t be too wordy.
    - Fully date every contact concerning service users (day, month, year) and make clear who has made each entry (e.g. signature and designation). Common sense must play a part in deciding how multiple daily contacts are recorded; e.g. “three attempts were made to contact the service user.”
    - Clearly record decisions and the decision making process on the case.
    - In complex cases, if further action is required, use ‘action/planning’ statements at the end of each diary entry, so that ongoing action is clearly recorded. This enables other staff to respond to enquiries and provide intervention in the absence of the allocated member of staff. Make sure that action statements are clear and specific regarding the tasks outstanding, and identify accountability for implementing the individual tasks.
  • All recording must show respect for diversity:
    - many of the issues relating to equal opportunities follow from quality of language. Staff should be aware of their own views and how these are expressed. It is important to be aware that some service users and their networks may not share these views
    - recording needs to be sensitive to differences in culture, class, language, race, gender, disability, sexuality and religion
    - check with the service users how they spell their name and how they wish to be addressed. Don’t assume we all have the same naming system
    - avoid stereotypical language
  • All recording must be timely:
    - remember that ASCC is a “real time” electronic record; therefore timely recording is imperative
    - record write-ups from any assessments, follow-up visit or any joint visits, on the day they are completed or at the latest by the next working day, within 24 hours of the visit, unless exceptional circumstances prevent this from happening, in which case make it clear that this is a late entry
    - write up interactions, phone calls and other contact with service users, carers and colleagues immediately and not later than within 24 hours of the contact in all circumstances unless exceptional circumstances prevent this from happening, in which case make it clear that this is a late entry
    - note any issues arising from emails from the Emergency Duty Team on the diary sheet of the appropriate service user and add the email as an attachment on the day that they are received.

 


Version control: Guidelines Vn 1 This page updated 28 July 2011