A common phrase you may hear in the care industry is “if it isn’t recorded, it didn’t happen”. But just recording alone is not good enough, the quality of records made by staff is critical in evidencing that people’s needs are met and that risks are managed.
· Provide evidence of the care and support provided - this must link to the person's care plan and must show how the care and support have been provided. If the care plan and the records are compared it should be easy to identify the links between them.
· Show the input of the person – the care records must show that the person was included in their care, a participant rather than a passenger so to speak. This requires the person making the records to think about how they construct the record so that it shows who did what.
· Demonstrate choice, voice, and control – this is essential, and the records should show how people are supported to have genuine choices about how their care is provided, supported to have a voice, and above all have control over how the care is provided to meet their outcomes that day.
· Provide evidence of how care contributes to meeting outcomes – outcomes are the intended result of the care intervention, records must not only link to outcomes but must show how every action has worked towards meeting outcomes.
· Identify changes in need – people’s needs change, hopefully for the better but often they become more significant. Records must show how needs are monitored and responded to.
· Provide evidence of proactive care- care and support must focus on a proactive rather than a reactive approach. This means anticipating future needs and issues and evidencing that these are monitored and responded to before they become problems.
· Show continuity of care – it should be clear from care records that social care workers have read and responded to the records made by the worker who provided the previous care intervention, it should also be clear when workers have provided information for workers who will be providing the next care intervention.
· Written at the time – this is essential, not only is it a legal requirement but the quality of the record diminishes significantly with time.
Your records must
· provide clear evidence that the care plan was followed and how it was followed.
· identify any deviations from the care plan and why this was.
· identify any possible changes required to care plans and risk assessments and how these were responded to.
· show how risks were managed and any changes in risk.
· records made by care workers should then evidence that the revised care plan and risk assessment have been followed in practice.
DNA – Do Not Abbreviate
Do Not Abbreviate - Care abbreviations can mean very different things to the public. Often, the use of abbreviations saves no time at all, increases the risk of confusion by staff, and is not consistent with the Accessible Information Standard and the requirement to communicate with people in their preferred format.
Fact not fiction
Records should record facts, if opinions are recorded then the record must make it clear that it is the opinion of the care worker. How can a care worker record “all well on leaving” if they do not back this up with some evidence of why all was well?
Punctuation and grammar
Records made without punctuation risk unconnected events becoming connected. E.G “X is in a bad mood today her son visited” implies that X is in a bad mood because her son visited. Also, “in a bad mood” is the opinion of the care worker and this has not been backed up with any supporting evidence. If the record was made as “X was not very chatty today, she said that she felt a bit down. X’s daughter visited today ” then her mood is clarified with evidence and her daughter is not being accused of being the cause of the mood.
Records are the only proof of the great job you do
If we go back to the opening statement “if it is not recorded then it didn’t happen” then it is clear that good records provide the only evidence that you do a great job of; meeting needs, managing risk, promoting independence, identifying changes in need or risk, involving the person, showing knowledge, skills, and competence. An ineffective recording is a missed opportunity to evidence your good work and good outcomes for our clients.
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