Recording and Keeping Records
A record in adult social care is:
'Any recording made, or information held by the local authority about a person with care and support needs and/or a carer with support needs need's'.
Examples include, but are not limited to:
- Correspondence (letters, emails and telephone transcripts);
- Date of birth, address and contact details;
- Accommodation (e.g., type, layout, details of alarms fitted, accessibility);
- Legal status (e.g., immigration);
- Legal documents (e.g., lasting power of attorney, advance decision, court orders);
- Referrals received or made;
- Contemporaneous handwritten notes by social workers, occupational therapists and others;
- Local authority reports relating to the person's/carers situation and needs (e.g., assessments, care and support plans/support plans, risk assessment, review reports);
- Information gathered as part of a safeguarding enquiry;
- Reports provided by other organisations or professionals;
- Information shared by family and/or carers;
- Records of conversations relating to the person/carer (e.g., conversations with them, or professional conversations about them);
- Anonymous concerns;
- Financial statements;
- Any other relevant information.
Nobody should see recording as an administrative burden to complete as quickly as possible-it should be recognised and valued as an integral and important part of what we do.
Good recording:
- Supports the delivery of good care and support;
- Promotes effective communication internally and with other organisations;
- Reduces duplication for everyone;
- Helps others to quickly understand a situation/need/concern/risk;
- Helps prioritise interventions and make sure they are proportionate;
- Helps identify themes and emerging patterns;
- Helps recognise achievement and progress;
- Is key to accountability and transparency-why a decision has been made;
- Is evidence during court applications or periods of challenge and investigation;
- Can aid learning when things go wrong.
See Google link
Every person that has requested or received support or services from the local authority should have an electronic case record.
Unless the timeframe is specified, records should be made in a timely way as near to the time that the actual event being recorded took place.
Timely recording will reduce the likelihood of inaccuracies and prevent unnecessary delays in taking any action that may be required.
Records should usually be completed by the practitioner that is primarily involved or has directly taken part in or observed the event/conversation/meeting that needs to be recorded.
Where this is not possible, and records are completed or updated by someone else it must be clear from the record which practitioner provided the information. For example, if a practitioner has telephoned in with some urgent information or to seek the guidance of a manager whilst on a visit.
The following must all be recorded:
- All written communication received or sent in relation to a person with care and support needs (or a carer with support needs). This includes e-mail, letters, text messages and other forms of communication;
- All telephone conversations with or about a person with care and support needs (or a carer with support needs);
- All reports received about a person with care and support needs (or a carer with support needs);
- All visits, meetings or appointments attended by the Local Authority.
Where relevant, all the following should be 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.
Records of Decisions
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.
Where a manager is asked for advice or guidance from a practitioner, the manager should record the advice, guidance or instruction given and their reason for doing so.
Last Updated: May 23, 2023
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