Recording and Keeping Records

Amendment

In September 2022, this NEW tri.x procedure has been added to the Universal Procedures section. A reference and link has also been added to all occurrences of the following text: “All recording should be in line with local recording requirements.”

September 22, 2022

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'.

Examples include, but are not limited to:

  1. Correspondence (letters, emails and telephone transcripts);
  2. Date of birth, address and contact details;
  3. Accommodation (e.g., type, layout, details of alarms fitted, accessibility);
  4. Legal status (e.g., immigration);
  5. Legal documents (e.g., lasting power of attorney, advance decision, court orders);
  6. Referrals received or made;
  7. Contemporaneous handwritten notes by social workers, occupational therapists and others;
  8. 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);
  9. Information gathered as part of a safeguarding enquiry;
  10. Reports provided by other organisations or professionals;
  11. Information shared by family and/or carers;
  12. Records of conversations relating to the person/carer (e.g., conversations with them, or professional conversations about them);
  13. Anonymous concerns;
  14. Financial statements;
  15. 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:

  1. Supports the delivery of good care and support;
  2. Promotes effective communication internally and with other organisations;
  3. Reduces duplication for everyone;
  4. Helps others to quickly understand a situation/need/concern/risk;
  5. Helps prioritise interventions and make sure they are proportionate;
  6. Helps identify themes and emerging patterns;
  7. Helps recognise achievement and progress;
  8. Is key to accountability and transparency-why a decision has been made;
  9. Is evidence during court applications or periods of challenge and investigation;
  10. Can aid learning when things go wrong.

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:

  1. 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;
  2. All telephone conversations with or about a person with care and support needs (or a carer with support needs);
  3. All reports received about a person with care and support needs (or a carer with support needs);
  4. All visits, meetings or appointments attended by the Local Authority.

Where relevant, all the following should be recorded:

  1. Time and date;
  2. The type of communication/contact;
  3. Who sent the communication/made the contact;
  4. Who was present at any visit/meeting/appointment;
  5. The relevant discussions that took place during or after the contact/visit etc.
  6. 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.

All records - including communication being sent to others

Records must be written concisely and in plain English.

Use of technical or professional terms, acronyms and abbreviations must be kept to a minimum and explained in a way that makes the recording accessible to everyone, including the person/carer 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 their opinions are recorded, practitioners must provide the rationale upon which those opinions are based.

Records must also distinguish between first-hand information and information obtained from third parties.

Electronic records

Records should be made using the right electronic template.

Paper records

Handwritten records must be legible, signed and dated.

The views, wishes and preferences of the person with care and support needs (or carer with support needs) must be evident in records and related to the sequence of decisions taken and/or arrangements made.

Wherever possible, records should be recorded in the person's/carer's own words and from their point of view, clearly showing the outcomes they want to achieve.

When recording, everyone 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:

  1. Respect and value differences of opinion and experiences;
  2. Don't use language or expressions others may find inappropriate-this can sometimes be subtle and linked to cultural differences;
  3. Be aware of and avoid using stereotypical language;
  4. Do not make assumptions about what someone may want/not want or is trying to say based on any protected characteristics (above);
  5. Do not rephrase what a person has said;
  6. Ensure that people with specific communication needs can contribute to and access their records in the same way as those without such needs.

This section contains 2 examples of good recording and 2 examples of poor recording.

Case Note

I visited Mr X with the intention of completing a review of his care package but was delayed by 15 minutes due to bad traffic. When I arrived Mr X spoke to me in a raised voice, began swearing at me because I was late for the visit, and began pointing his finger in my face. I felt intimidated by his behaviour which I perceived to be aggressive and explained to Mr X that I would come back and complete the review next Tuesday with a colleague present in addition. I have since phoned Mr X to confirm the new appointment. During the phone call Mr X apologised for his behaviour when I visited this morning, explaining his medication affects his mood in the morning.

 

Professional email

Subject: Direct Payment setup

Dear Direct Payment Team,

Please can you set John Smith (Ref P6109) up with a direct payment. He has not got capacity but his brother (Adam Smith - see in 'contacts') is setup with LPA, lives locally and has said he willing to act as an authorised person and manage a direct payment on his brother's behalf. John expresses anxiety at different people coming in the house so has not been happy with agency carers coming in and out. I discussed this with John and Adam during the assessment. John would be open to having a consistent personal assistant and his brother Adam thought this could work well. His neighbour (Sally Jones - see in 'contacts') is a family friend and might be open to acting as a personal assistant.

Kind regards,
Fred

Case Note

I visited Mr X and he was very aggressive, so I did not conduct a review at that time. New meeting time TBC.

 

Professional email

Subject: Direct Payment setup

Dear Direct Payment Team,

Please can you set John Smith up with a direct payment. He hasn't got capacity, contact his brother. I think he'd benefit from employing his own PA as he doesn't like the agency he is using!

Kind regards,
Fred

Different processes and functions have specific recording requirements, over and above the general good principles of recording explained above.

When carrying out these processes and functions, you should refer to relevant guidance to ensure those recording requirements are met:

Guidance for specific recording requirements
Type of Record Relevant Guidance on tri.x
Safeguarding records Safeguarding Adults
Outcome of referrals Deciding the Outcome of a Contact or Referral
Needs assessment Agreeing Needs and Making a Formal Record
Care and Support Plans Care and Support PlanningSupport PlanningThe Reablement Plan
Review Deciding the Outcome of a Care and Support Plan Review and Making a Formal Record
Deciding the Outcome of a Support Plan Review and Making a Formal Record
Deciding the Outcome of a Reablement Review and Making a Formal Record
Risk Assessment Risk Assessment
NHS Continuing Healthcare Checklist and DST NHS Continuing Healthcare Procedure
Court applications and statements Mental Capacity Act 2005 Resource and Practice Toolkit: The Court of Protection
Social Circumstance Report Social Circumstances Report
Human Rights Assessment No Recourse to Public Funds (NRPF)
Continuity of Care notifications Continuity of Care Arrangements
Cross Border Placements Cross Border Placements
Transition assessments, plans and reviews Agreeing Needs, Making a Formal Record and Next Steps
The Transition Plan
Reviewing a Transition Plan

People with care and support needs and/or carers with support needs should be informed about the records kept about them and the reasons why.

This includes:

  1. What data is collected on them;
  2. How it is used;
  3. Who it might be shared with; and
  4. How long it will be kept for.

This information should be readily available in the local authority's Privacy Notice.

All records, irrespective of whether they are physical or electronic, are confidential. They must be handled and stored securely.

Paper records should be kept to a minimum, but where they are necessary, they must be stored in a locked cabinet or drawer, that can only be opened by those with authority to access the records. They should only remain unlocked or open for as long as is necessary to undertake the work task in hand.

Unless paper records are actively being worked on, they should be stored securely as above. They should not be left on desks or anywhere else unprotected.

Records should not normally be removed from the secure location where they are usually kept. If it is necessary to take records on a visit or to work from home, adequate measures should be taken to protect personal information:

  1. Let a manager know what records you are removing and why;
  2. Take copies not originals if possible;
  3. Don't take anything it is not essential to take;
  4. Store records securely e.g., in a zipped bag;
  5. Never leave records unattended (e.g., in your car, home or on a visit);
  6. Replace records as soon as possible (or destroy copies securely).

Never show a paper record to anyone unless they have the authority to see it.

Should the situation ever occur where a paper record is lost or mislaid, this must be reported immediately to a manager and every reasonable effort should be made to obtain their recovery.

Where relevant local Data Breach Policy must be followed.

Notebooks

Notebooks used to make notes during visits/meetings or appointments should be treated as a paper record and protected as such.

When notes have been recorded, relevant notebook pages should be removed and destroyed securely (see below).

Desktops in offices

  1. Make sure that screens are not overlooked by anyone that is not authorised to see the information;
  2. Lock your screen when away from your desk or not actively working on the information (e.g., taking a break);
  3. Shut down desktops when you will/may not be returning;
  4. Delete electronic information when no longer needed (for example when an email has been recorded).

Mobile devices

For guidance on storing and protecting records when using mobile devices, see: Storage of Data on Practitioners' Mobile Devices.

Everyone is required by law to complete data protection and information governance training, including refresher courses.

For further information on how the local authority must meet this requirement, see: ICO website, Training and awareness.

Personal information must not be kept any longer than necessary for the purpose(s) for which it was collected.

Some records must be kept longer than others.

Guidance can be found in the Local Policy on the Retention of Records.

When destroyed, 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.

Records should only be accessed when there is a legitimate work reason for doing so.

Records must NEVER be accessed for personal reasons.

If you know of or become aware of any potential conflicts of interest this must be raised with your line manager. For example, if someone you know starts to use services, or if someone you know has asked you to find out information about someone.

For guidance about information about a person or carer that must/should/can/cannot be shared, see:

Everyone is responsible for ensuring:

  1. Good practice in case recording is followed;
  2. The local authority's policies and procedures relating to case records and data protection are adhered to;
  3. Personal data is processed with due care in order to avoid any potential information breaches;
  4. Any information breaches are reported to managers.

Managers are responsible for ensuring:

  1. Good practice in case recording is followed by those reporting to them;
  2. Everyone is aware of record keeping requirements and the local authority's policies and procedures relating to case records and data protection;
  3. Everyone follows good practice with regards to processing personal data in order to avoid any potential information breaches;
  4. Any information breaches are investigated and escalated appropriately.

Quality assurance and monitoring processes should be in place to ensure the above.

For example:

  1. Through supervision;
  2. At the point of case closure/transfer;
  3. Through case file audit.

Last Updated: September 22, 2022

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