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Record Keeping – Recording Guidance

This chapter was added to the manual in April 2015.


Contents

  Introduction
  Record Keeping Principles
  The Context
  Record Keeping by All Agencies
  What to Record
  When Should Information be Recorded?
  How to Record Information


Introduction

All organisations should refer to their own professional guidance on record keeping.

Good record keeping is a vital component of professional practice. Whenever a complaint or allegation of Abuse is made, all agencies should keep clear and accurate records. Each agency should have procedures for incorporating all relevant records into a file to record all actions taken. All records must be stored in accordance with your own agency’s policies with regard to the Data Protection Act 1998.

When abuse or neglect is raised managers need to look for past incidents, concerns, risks and patterns. In many situations, abuse and neglect arise from a range of incidents over a period of time. In the case of providers registered with the Care Quality Commission (CQC), records of these should be available to service commissioners and the CQC so they can take the necessary action.

Records should be kept in such a way that the information can easily be collated for local use and national data collections. Adult Social Care files may need to be made available to the courts. Access to files may also be requested by service users.

In order to carry out its functions, the Safeguarding Adults Board (SAB) will need access to information that a wide number of people or organisations may hold (See also Safeguarding Adults in Lancashire and Cumbria).

All agencies should identify arrangements, consistent with principles and rules of fairness, confidentiality and data protection for making records available to those adults affected by, and subject to, an enquiry. If the alleged abuser is using care and support themselves, then information about their involvement in an adult Safeguarding Enquiry, including the outcome, should be included in their case record. If it is assessed that the individual continues to pose a threat to other people then this should be included in any information that is passed on to service providers or other people who need to know.


Record Keeping Principles

Principles of Recording Information Across all Health and Social Care Agencies

Best practice in recording is based on key principles of partnership openness and accuracy.

Good quality case recording is essential in ensuring:

  • Continuity of service to individuals when staff are unavailable or change, or when a service resumes after a period of time;
  • Effective risk management practices to safeguard the well-being of individuals in receipt of services, especially in emergency situations;
  • Clarity of the assessment process and decision-making in relation to the mental Capacity of all service users/patients;
  • Effective partnerships between staff, individuals, their families and Carers, and other providers;
  • Clarity of information for everyone involved in the planning and delivery of services, and in the event of investigations, inquiries, or audits;
  • Adequate information for staff and managers working to ensure the best possible utilisation of available resources;
  • Support for people and carers receiving services with specific communication needs so that they may contribute to and access their records and key information.

Information should be recorded in accordance with the following key principles:

  • All relevant information must be recorded;
  • Manual records must be legible, signed and dated;
  • Records must be contemporaneous and kept up to date;
  • Records must be written in plain English and prejudice must be avoided;
  • Records must be accurate and adequate;
  • Records must clearly distinguish between statements of fact and opinion;
  • Managers must oversee, monitor and review all records;
  • Records should be kept securely;
  • Manual records moved to a new location must be monitored;
  • Professional analysis, thinking, rationale for all decisions;
  • Show management involvement, sign off of all key decision points;
  • Show referral by line manager to senior management/press office as needed.


The Context

Good record keeping is essential so that agencies are able to demonstrate that decisions were taken lawfully. Documentation in relation to Safeguarding Adults process can be central in providing supporting evidence when making referrals to the Disclosure and Barring Service Barred List, criminal cases, high court, Coroners Court, disciplinary hearings and complaints. Record keeping is an integral part of professional practice and should support decision making. Decisions and action taken should be supported by evidence and rationale so that intentions are clear.


Record Keeping by All Agencies

Each agency must keep comprehensive records of any work which it undertakes under the Safeguarding Adults Process, including all Alerts it receives and all Referrals made. Each agency should identify procedures to enable the records of all other relevant agencies and abused person's records to be incorporated into a comprehensive file which details all actions taken.


What to Record

Staff should be given clear direction as to what information should be recorded and in what format. The following questions are a guide:

  • What information do staff need to know in order to provide a high quality response to the adult concerned?
  • What information do staff need to know in order to keep adults safe under the service’s duty to protect people from harm?
  • What information is not necessary?
  • What is the basis for any decision to share (or not) information with a third party?

As well as the above, the following should be considered:

  • All entries must provide factual information, e.g. times, dates, names of people contacted;
  • Avoid expressions of opinion (remember that the person you are writing about may have the right to read what you have said);
  • There should be a clear link between evidence recorded and actions planned/recommended;
  • All contact with the Adult and alleged perpetrator must be recorded;
  • Record the exact words the Adult and alleged perpetrator used;
  • All consultation with a Manager and/or Senior Manager must be recorded;
  • When contacting other agencies the questions asked and information received must be recorded;
  • If a decision is made not to contact the Police, the details of why this decision was made and on whose authority it was made must be recorded;
  • All telephone calls, those received and made in relation to the abuse, must be recorded even if there was no reply to outgoing calls;
  • Those who attend Strategy Meetings must be named;
  • 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;
  • All entries to be completed with name of person making entry printed, signed and dated;
  • A professional analysis of evidence, recommendations and rationale for these;
  • Use Body Maps (see Body Maps) to illustrate physical injuries;
  • When contacting other agencies the questions asked and information received must be recorded.


When Should Information be Recorded?

  • Records must be kept from the time that a concern, allegation or disclosure is made;
  • Each entry must be dated and timed;
  • The name of the person recording the information must be written in full. Do not use initials.


How to Record Information

  • All 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 a word(s);
  • Correction fluid must not be used;
  • All records concerned with Safeguarding Adults are strictly confidential;
  • Health professionals must record all information in line with the record keeping guidance of their own professional body.

End