Good Recording
Scope of this chapter
This chapter is about good recording.
Recording is an integral and important part of what we do. It should never be seen as simply an administrative burden to go through as quickly as possible, but as central to good, person-centred support.
Note: Some of the things we do have specific recording requirements, over and above the general principles of good recording covered in this chapter. For example, recording medication administration, risk assessment or best interest decisions. When carrying out these tasks, you should always refer to relevant guidance to ensure those recording requirements are met.
Being able to record effectively is a vital skill that everyone in the service must already have or be committed to developing. Because of this, it is a core principle and value. This means it applies to everyone and is always relevant when planning for or providing care and support.
Relevant Regulations
Regulation 9: Person-centred care
Regulation 10: Dignity and respect
Related Chapters and Guidance
- Communicating Effectively
- Confidentiality and Information Sharing
- Consent
- Partnership Working
- Preventing Abuse and Neglect
- SCIE: Social care recording
- LGO: Good record keeping
Amendment
In November 2024, this new chapter was added into the Core Values and Principles section of the contents list.
Good recording underpins safe, effective, compassionate, high-quality care. It ensures that records communicate the right information clearly, to the right people, when they need it. It is an essential part of achieving good outcomes for people who use our service.
Good recording:
- Supports us to provide good care and support;
- Promotes effective communication (with the people we support, each other, families and with other organisations and professionals);
- Reduces duplication for everyone;
- Helps us to quickly understand a situation/need/concern/risk, so that timely action can be taken;
- Helps us prioritise our interventions and makes sure they are proportionate;
- Helps us to identify themes and emerging patterns;
- Helps us recognise achievement and progress;
- Aids learning when things go wrong (for example from accidents, incidents, safeguarding concerns, complaints).
Good recording is also key to accountability and transparency – explaining why a decision has been made or an action taken. Records can be used as evidence during a formal process such as a CQC assessment or court application.
A record is ‘any recording about a person with care and support needs made or held by the service’.
Records can be handwritten, hard copies, electronic or digital in nature (e.g. Digital Social Care Records (DSCR)).
Examples of records you may need to make include, but are not limited to:
- Care records (records of support, care or treatment provided, records of consent, conversations with the person, family and professionals etc.);
- Forms containing personal information (such as date of birth, address, contact details, emergency contacts, professional contacts);
- Assessments of need;
- Reviews;
- Care and/or Support Plans;
- Records of concerns;
- Incident reports (e.g. accidents, behaviour that challenges, unplanned events);
- Risk assessments;
- Mental capacity assessments;
- Referrals made;
- Letters and emails sent.
Examples of records made by others that we could hold include:
- Letters and emails received;
- Assessments of need completed by others (e.g. a social worker, Occupational Therapist);
- Plans completed by others (e.g. local authority Care and Support Plan, ICB Care Plan);
- Reports completed by others (e.g. review reports, risk assessment, medical reports);
- Financial information;
- Complaints;
- Legal documents (e.g. Court Order, DoLS authorisation).
Recording should be done, as much as possible, in conjunction with the person it is about.
The views, wishes and preferences of the person must be evident in records.
Wherever possible, records should be recorded in the person's own words and from their point of view, clearly showing the outcomes they want to achieve.
Unless the timeframe is specified (for example when recording medication), records should be made in a timely way as near to the time that the actual event being recorded took place. Delays in making a record or leaving a record incomplete can hinder colleagues working with the same person, lead to duplication and impact on the person’s wellbeing or safety.
Sometimes delays in recording will be unavoidable – if this happens it is important to note in the record that there were delays in recording and the reasons for this. You should NEVER attempt to disguise a late recording.
Wherever possible, records should be made by the staff member that took part in or observed the event/conversation/meeting that needs to be recorded. If this is not possible, it must be clear from the record which staff member provided the information.
Where the registered person or a line manager is asked for advice or guidance from a staff member, the registered person/line manager should record the advice, guidance or instruction given and their reason for doing so.
This chapter is about the general good principles of recording. Some of the things we do have specific recording requirements, for example recording medication administration, risk assessment or best interest decisions. When carrying out these tasks, you should always refer to relevant guidance to ensure those recording requirements are met.
The following should always be recorded:
- Proportionate records of the support, care or treatment provided;
- All written communication received or sent in relation to a person being supported by the service. This includes e-mail, letters, text messages and other forms of communication;
- All telephone conversations with or about a person being supported;
- All meetings with or about a person being supported (for example meetings with GP or social worker);
- All reports received about a person being supported;
- All visits, meetings or appointments you support a person to attend;
- Any concerns you have about the wellbeing or safety of a person being supported;
- All accidents and near misses that did or could have resulted in harm to a person being supported.
Where relevant, the following should be clearly recorded:
- Time and date;
- The type of communication/contact;
- Who sent the communication/made the contact;
- Who was present at any visit/meeting/appointment;
- The relevant discussions that took place during or after the contact/visit etc.
- Actions or decisions taken and by whom.
The service must keep an accurate record of all decisions taken in relation to care or treatment, including consent records.
Records of decision making should be clear and comprehensive yet proportionate to the circumstances.
Anyone reading recordings should be able to (as quickly and easily as possible) understand who has made a particular decision, how/why and the impact of it.
Records must be written concisely and in plain English.
Use of technical or professional terms, acronyms and abbreviations should be kept to a minimum and explained in a way that makes the recording accessible to everyone, including the person it is about.
Every effort must be made to ensure records are factually correct.
Records must distinguish clearly between facts, opinions, assessments, judgements and decisions.
Where opinions are recorded, you must provide the rationale upon which those opinions are based.
Records must also distinguish between first-hand information and information obtained from third parties.
When recording, you should be mindful about the existence of any unconscious bias or discrimination on the basis of race, culture, religion, age, gender, disability, or sexual orientation.
Steps should be actively taken to prevent this:
- Respect and value differences of opinion and experiences;
- Don't use language or expressions others may find inappropriate-this can sometimes be subtle and linked to cultural differences;
- Don’t be afraid to ask the person how they wished to be referred to if you are unsure;
- Be aware of and avoid using stereotypical language;
- Do not make assumptions about what someone may want/not want or is trying to say based on any protected characteristics (above);
- Do not rephrase what a person has said;
- Ensure that people with specific communication needs can contribute to and access their records in the same way as those without such needs.
For further guidance and examples, see:
GOV.UK: Writing about ethnicity.
GOV.UK: Inclusive language: words to use and avoid when writing about disability.
The following top tips are adapted from the SCIE social care recording resource. The resource aims to support social care staff, including service managers, frontline care workers in care homes and home care, personal assistants, and other care providers, to improve their recording skills.
To access the resource in full, see SCIE: Social care recording. In the resource there are also some helpful videos that demonstrate the importance of good recording.
| Tip | Guidance |
|---|---|
| Person-centred | Try to make your recording as person-centred as any other part of your practice. Social care records can shape significantly the services a person receives and by extension the life they lead. |
| Accurate | Whatever it is you are expressing – fact or opinion – state accurately what is happening, or what you believe, and avoid vagueness wherever you can. |
| Real | The fact that lots of people, including the person about whom the record is kept, may read a record, is one of the challenges of recording, particularly when aspects of their behaviour may be causing them or others difficulties. This can lead to vague wording. Try to find the middle ground between the delicate yet uninformative (e.g. she has issues with personal hygiene) and the blunt but disrespectful (e.g.she smells terribly). |
| Timely | Everything that goes to make up a good social care record – person-centredness, accuracy, detail, reflection, and analysis – is easier to achieve if a record is made promptly, when things are fresh in the memory. |
| No jargon-plain English | Too much jargon quickly makes what we record incomprehensible to the person being supported, to each other and even to professionals. |
| Evidence-based | You must make sure that you can substantiate what you’re saying. So, if you are stating a fact, be sure that it’s an accurate one. If it is an opinion, make sure you can back it up with evidence from what you’ve seen or heard. |
| Reading the previous record | Read previous records. Not doing so may mean that you miss potentially crucial information about a person’s history, and about how best to support them. It can also frustrate people who end up having to tell their story more than once. |
| Succinct | Avoid vagueness. Concentrate on writing detailed, factual reports, with opinions being clearly expressed where appropriate, and avoid repeating yourself. |
| Holistic | Wherever possible, try to have one record that presents a coherent, holistic picture of the person rather than lots of separate records. This can make it easier to share records and work together with others. |
| IT compliant | Most social care records are made on IT systems. Make sure you know how to use the IT system effectively to record appropriately. |
| Professional | Your record is an important document which represents yourself, the organisation you work for and most importantly the person you are supporting. You must try, therefore, to make sure that in all areas of what you do, you adhere to the highest standards. |
The service (and every individual employee) has a duty to respect and protect personal information. There is another chapter in the handbook that explains the steps that should be taken to protect personal information and maintain confidentiality, and when/how such information can/should be shared.
The service is required to store and destroy records in line with current legislation and nationally recognised guidance.
If the service is commissioned or delivered by the NHS or a Local Authority, most of the records it holds should be retained for the period set out in the NHS England Records Management Code of Practice for Health and Social Care.
Under the Code, most records must be retained for 8 years.
For further guidance, see NHS England: Records Management Code of Practice.
Where a particular record does not come under the code, it must not be kept any longer than necessary for the purpose(s) for which it was collected.
If the service is never commissioned by the NHS or a Local Authority (i.e. it only contracts directly with individuals), the above Code can still be used for guidance but the legal framework for managing records is set out in the Health and Social Care Act 2008.
When destroying information, this should be done in a manner that will continue to protect personal information. For example, confidential waste bins or cross-cutting shredders.Personal information should never be simply thrown away in normal waste.
Everyone is responsible for:
- Following good practice in their own recording;
- Adhering to the services policy and procedures relating to recording and data protection;
- Taking due care to avoid any potential information breaches when processing personal data;
- Reporting any information breaches to the registered person/ line manager.
The registered person/line managers are responsible for ensuring:
- Good practice in recording is followed by those reporting to them;
- Everyone is aware of record keeping requirements and the services policy and procedures relating to recording and data protection;
- Everyone follows good practice with regards to processing personal data;
- Any information breaches are investigated and escalated appropriately.
Quality assurance and monitoring processes should be in place to ensure the above. For example, through supervision or file audits.
Last Updated: October 25, 2024
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