Recording standards for care

Recording occurs within a context of professional accountability and the duty of care.                         

What this means is that as long as you properly undertake your duty of care and record clearly not only what you did but also why you did it (the information your decision was based on) you are legally discharging all that is required of you, as long as this is reasonable and legal.                        

For example, this means that if you walk into a service user's room and see an unplugged nurse call then you can reasonably be expected to take action. If any recording shows you saw this and did nothing, and, if at a later date an issue occurred and the service user suffered harm, then you can be held to have some accountability for that harm.                        

In the real world it is never that easy and there are many complicating factors. Someone may not tell you the truth, they may refuse to tell you, forget to tell you, not pass on a message, or you could not reasonably have been expected to see something. The general rule is that you can only be considered accountable based on the information you could reasonably be expected to know or to have found out. If at a later date information comes to light that indicates a risk existed previously you cannot be held accountable unless it can be proved that you were negligent in not uncovering that information.                            

Good recording will allow anyone who is authorised and has a relevant care background to easily and confidently access relevant information regarding a service user. Such information must be easily and readily accessible, in an agreed format and agreed location whilst ensuring security confidentiality, consistency and ease of access.                            

Some providers hold records in either/or electronic and paper formats. The content of both types of recording will be the same,  however the formats will be different. The same principles of recording defensible decisions, and the record being able to be easily followed by another social care professional apply to both types of recording.                         

All information needs to be signed and dated and attributable to an individual so clarification can be sought if needed. Where the signature is not easy to read the name of the individual making the recording should be printed. In the case of electronic recording the system must hold in the background details of all entries on who entered what, when and who changed it and when and exactly what was changed. This is an electronic signature, however entering names on documents as well is helpful.                            

Very generally there are three types of recording that can be considered;                         

Recording of factual information e.g.                        

•  personal information recording (name, address, age, ethnicity, disability etc.)
• medication, time dosage, medication and required cross checks
• logging activities, bathing, toileting, trips etc.
• logging visits and visitors,  telephone calls etc.

Recording of an observation/incident e.g.                        

• an incident report
  
• a report of a contact or a visits e.g. a home care or reablement visit

Recording of an assessment, a decision/plan e.g.                        

• a care assessment
• a risk assessment
• a mental capacity assessment
• a decision to enter residential care

In all of the above 3 categories a few general rules apply;                         

• any record made during the delivery of social care is a legal document and therefore any recording must be clearly linked to the person who wrote it by a signature and a date of recording. If this is not complete the record has no legal validity. This means a document or record must be dated and then signed by the person writing it, just like a cheque. This also allows the reader to know who to ask for clarification and to be sure they are not acting on out of date information
• any record must be legibly attributable to a named individual, which is different to signing a document. Most signatures cannot be understood by an external person, such as an inspector or auditor. If you don't understand the record or have a question and you don't recognise the signature you don't know who to ask for more information
• any recording should be a complete communication, telling the whole story and be fully and easily legible and in the correct format. Records are a form of communication. You should be able to read a recording with no prior knowledge of the case and be left with no outstanding questions as to that recording
• records must be easily accessible, and people who need to access them must know where to look for them. Paper files should be well organised, indexed and kept in a secure, well known location
• no or minimal use of jargon or abbreviations. It may not be another social care professional who needs to read the record e.g. service user, ambulance staff, doctors, carers, family etc.
• when referring to a person use their full name and there role in the case. In 12 months a new worker may not know that Sue who made the phone call is in fact an occupational therapist, which may or may not be important
• any alteration or correction to a paper record should take the form of a single line through the recording being deleted. The correction should be written in and initialled, if done by the person who originally made the recording. This is so it remains legible in case of audit and in case the correction was incorrectly applied
• any alteration to an electronic record must also be auditable. This facility is provided by most electronic systems via metadata, which clearly identifies who changed what from what to what and when the change took place. If you wouldn't change a paper record then you should not change an electronic record
• in any case recording, be it paper or electronic, must accurately reflect what has occurred. Changing an error in recording or correcting information is acceptable. Changing information to give anything other than an accurate description of events may be a disciplinary offence and advice must be sought from line managers before changes which give rise to concern are undertaken

This is the simplest case. It is a recording of factual information that something was observed to happen or someone did something.                         

In the case of recording factual information e.g. medication, visits or phone calls, it is important that;                         

• we clearly understand what it is we are being told by the record. For example, a call received, medication given etc.
• we know who recorded the information so we can ask if we are unsure
• to whom the information refers
• to when it refers - time and date

In the case of such things as phone calls or things people tell you you need to record who it was who told you. The fact you are told something is a fact. The content of what you are told is hearsay                            

In recording an observation one of the key factors is to distinguish between fact, hearsay and opinion, especially professional opinion.  What you saw yourself, what was said to you, what you know happened, as opposed to what you have been told, or what you think, or what your professional judgement is.                          

The important factors are;                         

• who is doing the recording? Is this first hand recording i.e. something you saw or second or even third hand i.e. someone told you?
• who is it about?
• what is it about?
• when is it about?

It is also important that you clearly differentiate these things into objective things you saw yourself, things you have been told, and things that are your opinion. For example, if you are making a judgement like the house was dirty, it is dirty in your opinion. Other examples could be Mr Smith was unclean, Mr Smith was drunk, Mr Smith was under the influence of drugs. These statements must be clearly identified as being in your opinion. Strictly speaking you should record that Mr Smith appeared drunk, or appeared to be under the influence of drugs, as only a medical test can determine as fact if either of these were true.                            

Assessments, decisions and plans are all part of similar process and hence the recording is based upon the same foundation.                         

That foundation of the process is the collection of relevant and appropriate information from service users, their families, carers and other professionals. The information is then analysed, in terms of the context, needs and aspirations of service users and in light of professional training, skills knowledge and experience, to arrive at a decision to do something or change something and then a plan is developed to support that change.                        

Any assessments, including risk assessments, care or service plans including any care or protection plan or reviews must be recorded in such a way that the link between the identified needs of the individual and the identified outcomes of any plan is clear. It should clearly identify how those outcomes will be achieved and who will be accountable for achieving them.                        

A good rule of thumb is that if, after auditing any such a record, you are left with any relevant questions regarding the case, the recording needs to be improved.                        

Any recording should accurately record that a proportionate and appropriate process has been followed, and that process wherever possible involves the service user and their circle of support;                        

In more detail the process involves:                        

• gathering appropriate and proportionate information regarding the potential service user, their environment and their circle of support. Particular attention should be paid to any relevant strengths that can be built upon and weaknesses that need to be addressed
• analysing that information in the context of the issues being addressed e.g. service provision, safeguarding and risk. In the context of the service user their needs, aspirations and capabilities, with regard to best practice and research
• from that analysis arriving at a decision or series of decisions that clearly reflect the information gathered and the analysis undertaken to reach that decision to take or not take an action, e.g. to provide home care, tele-care, or residential care
• have in place a process for monitoring and reviewing to ensure that any plans put in place are meeting the outcomes they were designed to achieve. The record should also include who will do this and how frequently

Where a service user has a file each service user should have a separate record/file in which documents and recordings can be easily located. These should be securely stored in a lockable cabinet.                         

All documents should clearly identify when they were created (dated) and who undertook the recording (named and signed with job role).                         

Personal basic details (for example name / d.o.b. / ethnicity/ next of kin  / address / GP etc/ important family members, contacts) should  be clearly and accurately recorded at the time of first contact. These should be regularly reviewed and updated, with the date of creation/alteration and review clearly recorded as required. This means that if you find the address on a record is wrong it is up to you to correct it and sign the change.                        

Essential, key components of every case record will ensure:                         

• every (significant) contact, observation, assessment review plan etc. concerning service users is recorded, including date  names of all individuals involved (staff, service users, any others) with the purpose of contact and any actions required. What is or is not significant will vary from individual to individual and is a professional judgement which if in doubt should be discussed with a line manager
• all decisions taken regarding the individual are recorded and clearly identified by the individual taking the decision, including in the case of significant best interest and mental capacity assessments
  
• the evidence on which decisions are based is clearly recorded
• there is clear evidence on the record showing when copies of key documents (e.g. assessments, care plans, safeguarding investigations, reviews, and minutes of meetings) are supplied to service users and carers
• the wishes, feelings and views of the service user are (where appropriate) ascertained at key points throughout the record, initial contact, assessment, review, change in care plan, risk assessment, closure etc. are recorded on the file, they are clearly identified and accurately reflect the views of the service users
• the full name and job title of the member of staff creating the record is clearly identifiable on the document
  

Records should include information under headings or in the format as directed by:                         

• relevant internal policies and procedures, legislation or Department of Health guidance. For example, personal details, assessments, running record, capacity assessments, risk assessment, reviews, confidential etc. Such formats must be consistent across service types e.g. residential, access and inclusion, home care
• the structure and format of records, the type of file colour and division will reflect local requirements set out by providers of services, care management procedures, and other relevant guidance
• each and every (significant) contact with the service user must be recorded. All entries should identify purpose of the contact, visit, meeting or telephone contact, who was present/involved, in terms of service user carers, staff, A.N.Others. Any action resulting from the visit, meeting or telephone contact should be recorded clearly
• for community care services, the assessment of the person's eligibility for social services will be clearly identifiable, and the content of the assessment and review of needs will be in accordance with care management and local processes.

The design of local forms to collate this information will reflect these considerations.                         

Records will show that users and carers;                        

1) Have been consulted and their views taken into account in any decisions or judgments, where appropriate

2) Have had their views recorded, including any disagreements and how these have influenced their care package

Case summaries / chronologies should be kept up to date to provide an accessible overview of each case

Records must indicate appropriate authorisation from managers                         

Note: Where a decision has been reached which includes legal advice received, details of the advice and the source of that advice must be recorded.                        

Where there is a paper file this should be organised to include as a minimum sections as directed by service area.                            

A good source of information on this subject is available on the web site Write Enough External link.                         

For more detailed information visit the Information Commissioner's External link web site.                        

Remember that a service user and/or their representative may have the right to access their files so anything written may be seen and read by the service user.                        

There must always be a good reason for recording and continuing to hold any information on service users and third parties and workers must always distinguish between fact, judgement and unverifiable information.                         

The amount of information collected and recorded must be the minimum necessary for the particular purpose, but be complete, i.e. all essential information appearing to be relevant relating to a particular decision or purpose must be recorded. In the case of medication this should include a method of ensuring complete auditing of stock control.                        

Information recorded must be accurate relevant and proportionate the content of case records and will include:-                         

1) Verifiable and factual information.                         

2) Descriptions of direct observation by the worker.                         

3) Wishes, feelings and views of service users                         

In each case any non-factual information, judgements, decisions, professional opinions, hearsay etc. must be clearly identified and recorded in a separate sentence or paragraph to objective factual information.                         

Unsubstantiated and unattributable information will be recorded on the file only if it is judged to be of current or possible future significance. The standing of this information must be absolutely clear. Attempts should be made to check its accuracy as quickly as possible and to record the results.                         

All decisions must be recorded indicating who was involved in the decision making, what information was taken into account and the reason for the decision, and where ever possible the service users agreement or point of view.                        

Where there is unresolved disagreement with a service user about recording or recorded facts, note this and record the service user's point of view as well.                         

There will be occasions where 'detailed' recording will be required and is likely to be used to cover what might be seen as significant events e.g. child protection or vulnerable adults. It should be born in mind that even where a detailed recording is required, this should still be as concise as possible.                         

When a case is closed or transferred to another service, the file should be in good order and in such condition that the essential details of the involvement with the service user can be clearly and easily seen.                         

The decision to no longer provide a service and close a case should be recorded and the case/key worker must ensure that the record is in good order and meets these standards.                         

The accountable individual is responsible for ensuring the case record is kept to the required standard and complies with the policy and procedural guidance on case records, care management procedures and meets statutory requirements. Line managers are responsible for ensuring that workers they are responsible for keeping their case records to the required standard.                            

All information must be signed and dated. Where the signature cannot be easily understood the name of the individual making the recording should be printed. In the case of electronic recording the system should hold in the background details of all entries, on who entered what, when and who changed it when and exactly what was changed. That this is an electronic signature is not an issue, however entering names on documents is helpful.