8.1 Record Keeping

1. Introduction

Good case recording is a vital component of professional practice. It supports continuity of care, risk assessment and risk management, documents thinking, decision making and actions taken. It is a professional aid to planning and analysis. Case files are legal documents providing an evidence trail of the work done with an adult, and their carer.

Good case recording includes a record of:

• work that has been undertaken;
• actions, and reasons for those actions;
• decisions, and reasons for those decisions;
• progress adults make towards their desired outcomes;
• views of the adult and their carers;
• the adult’s life history;
• professional assessment and analysis of risk.

1.1 Access to records

Practitioners should bear in mind at all times that adults, or their representatives, can request access to their files at any time. Records should, therefore, be made in line with the guidance below.

Case records may be made available to the courts in the event of a safeguarding or criminal enquiry and adult users of services may request access to information on their case file.

They are also a vital tool to enable staff to reflect on their practice and identify any gaps for support or development. They should be used as part of supervision, in conjunction with their supervisors / managers.

1.2 Practitioner guidance

Good record keeping is a vital practitioner practice tool, enabling staff to reflect on their practice, demonstrate their thinking, the rationale behind decision making, analysis of complex situations and management oversight.

It is not simply a record of what is happening; it should be actively used as a tool to provide a professional analysis of the situation and plans to support the adult and carer.

The use of genograms, chronologies and assessment records can help organise and analyse information.

Good record keeping enables managers to identify practice gaps and ensure additional support or development opportunities are offered to staff.

Management review of adults records with their staff should be a routine part of supervision and appraisal.

2. How Should Information be Recorded?

Social care and health staff will often be working with adults and their carers with complex needs, over a period of time. In such situations it is crucial recording is well structured in order to ensure readability, and also to allow analysis and practitioner assessments to follow on from evidence based content.

General areas for an assessment framework are:

• physical health: past and present including mobility and care needs;
• mental / emotional / psychological health: past and present;
• social situation: past and present, including employment and family history, housing, the adult’s own values, wishes and goals.

In addition:

• records must be legible and if written should be in black ink;
• any alterations to records must be made by drawing a single line through the word, and correction fluid must not be used;
• professionals must record all information in line with the record keeping guidance of their own organisation and professional body;
• entries should be dated and signed and time of recording noted;
• records should be written with the readership in mind. They should be easy for the adult to read and understand;
• language should be plain, clear and respectful, keeping jargon and to a minimum;
• there should be a clear link between evidence recorded and actions planned / recommended.

3. What Information should be Recorded?

The following information should be documented in each adult’s records:

• biographical details;
• history;
• facts;
• events;
• ongoing work including discussions with other agencies and professionals, telephone calls and responses to these;
• actions taken and in relation to them the adults wishes, feelings, views and understanding of the actions should be recorded;
• decisions made;
• plans and contingency plans;
• professional analysis / assessment of evidence rationale for these and recommendations.

4. Principles of Good Practice

Case records should be recorded in accordance with the following:

• completeness: all information relevant to the adult and their circumstances should be documented. All action plans, decisions and key conversations and phone calls should be recorded;
• openness: as adults may request access to their file at any time;
• accuracy: all content must be accurate, facts must be distinguished from opinion;
• the adult’s voice: records should be drawn up in partnership with the adult and record their views, in their own words where appropriate, including whether they have given permission to share information. The adult’s voice should not be ‘missing’ from the case record. Practitioners may inadvertently focus on the views of a carer who may be more vocal, rather than the adult who may have difficulty expressing themselves;
• up to date: records should be up to date and written up as soon as possible;
• management oversight: files should be regularly reviewed by managers. Management involvement in casework should be clear, and decisions and recommendations dated and signed off by the relevant manager
• summaries / continuity of care: large files should be summarised at regular intervals as the size of the record may otherwise make it difficult to manage. Records should, therefore, be focused. Important information should be highlighted and regular summaries / transfer summaries included, to make it easier to read and hand over from one member of staff to another;
• decision making: files must include a record of decisions taken and reasons for them;
• chronology of significant events: this should be included in the record;
• evidence based: so all decisions are supported by facts;
• mental capacity: it should be clear how this area of practice has been addressed in line with the Mental Capacity Act 2005;
• partnership working: records should show evidence of partnership working between staff, other professionals, other agencies, adults and their carers;
• resources: records should show evidence of the best use of available resources;
• communication needs: should be clearly addressed within the record;
• risk management and contingency planning: files should incorporate assessment, including risk assessment and contingency plans where appropriate;
• equalities issues: record the adult’s race /ethnicity, gender, religion, language, disability;
• security: all files must be kept securely.

5. Adult Safeguarding

Safeguarding cases are some of the most high risk situations for adults and their carers. Good case recording is therefore essential to ensuring the safety and wellbeing of adults and their carers in situations where abuse or neglect are of concern.

All agencies should keep clear and accurate records and follow their own agency’s recording policies.

In general, where there are safeguarding concerns regarding an adult, the following should be recorded:

• a full assessment including past incidents, concerns, risks and any patterns, as abuse and neglect often arise over a period of time
• if the alleged abuser is using care and support services themselves, information about their involvement in a safeguarding enquiry, including the outcome, should be included in their case record;
• if it is assessed that the adult continues to pose a threat to other people, this should be included in any information that is passed on to service providers or other people who need to know;
• all contact with any adults at risk of, or experiencing abuse or neglect, and alleged perpetrators must be recorded;
• the adult’s own words where appropriate, and recording the exact words of adults and / or alleged perpetrators;
• all consultations with a line or senior manager;
• if a decision is made not to contact the police in the case of an adult at risk of, or experiencing abuse or neglect, the details of why this decision was made and on whose authority must be recorded;
• those who attend key meetings and safeguarding meetings must be documented;
• the decisions taken at all meetings must be recorded;
• it is essential to demonstrate how an assessment of risk, responsibility, rights, autonomy and protection of the adult was undertaken;
• if no investigation is to take place, the reasons why and on whose authority this decision was taken must be recorded;
• use a body map to illustrate physical injuries or pressure ulcers etc, when necessary.