Policy Number:

Best Practice guidance for record keeping for child and family records

Document History

Version Date: / January 2009
Version Number: / 1
Status: / Approved
Next Revision Due: / September 2010
Developed by: / Angela Pogmore
Alison Higley
Policy Sponsor: / Angela Pogmore Alison Higley
EQIA completed: / yes
Approved by: / Clinical Governance Committee
Date approved: / February 2009

Revision History

Version / Revision date / Summary of Changes

Table of Contents

1.Aim

2.Background

3.Area for Implementation

4.Organisational Accountabili /Responsibilities i.e. CEO, Directors, Managers, Staff

5intended users

6.Definition

7.Equality Impact Statement

8.References and Associated Documentation

9.FULL DETAIL OF POLICY (including results of impact and risk assessments)

MAINTAINANCE AND MANAGEMENT OF CHILD HEALTH RECORDS

ELECTRONIC RECORDS

FILING

TRACER CARDS

SAFE TRANSPORTATION OF RECORDS

CLEAR DESK POLICY

RECORDING INFORMATION

10.Monitoring and Performance Management of the policy

11.Support and Additional Contacts

Policy Name/Summary Title

Best Practice Guidance for Record Keeping for Child and family reocrds

1.Aim

To ensure consistent adherence to the Trust Clinical Policy document and the NMC codes of professional practice for records keeping

2.Background

The Trust Clinical Records Policy provides the critical framework for all health records that are used by clinicians. Children and Family records have an additional complexity for which staff need clear direction to complete to fulfil their professional responsibilities for specialist practice. Safeguarding of children is incumbent on all staff using these records to maintain a high level of information and an agreed format to present the information

.

3.Area for Implementation

Across all sites and all staff in the county that deliver services to children and their families

4.Organisational Accountabili /Responsibilities i.e. CEO, Directors, Managers, Staff

The staff hold responsibility as registered nurses for their records keeping

The support staff’s entries are managed by their line manager

The operational managers hold responsibility for the staff they manage and any capability issues that arise.

The policy sponsor and the professional lead for the auditing of this guidance as part of record keeping audit twice yearly.

5intended users

All staff who provide a service to children and their families and work as part of the School Health Teams or Health Visiting Teams.

This section is to set out who will be the intended users of the policy. For clinical policies this can also include clinical specialty.

6.Definition

Use this section to set out any specific definitions that will aid with understanding and implementing the policy. For example, the Policy Development Framework uses this section to define the types of documents covered by the framework.

7.Equality Impact Statement

This section should contain the following two statements:

‘We welcome feedback on this policy/procedure/strategy and the way it operates. We are interested to know of any possible or actual adverse impact that this policy/procedure may have on any groups in respect of gender or marital status, race, disability, sexual orientation, religion or belief, age, deprivation or other characteristics.’

‘The person(s) responsible for equality impact assessment for this policy/procedure/strategy is/are {name and contact details}.’

‘This policy has been screened to determine equality relevance for the following equality groups: please refer to reference and associated documents. The policy is considered to have little or no equality relevance.’

8.References and Associated Documentation

Trust Clinical Record Policy 2008

NMC Codes of Practice – Record Keeping 2008

NMC Codes of Conduct 2008

Trust Clinical Records 2008

Safeguarding Policy 2008

Every Child Matters- Assessment Framework

CAF

Data Protection 2004

Information Sharing Protocols 2007

Children Act 2004

NMC Codes of Professional Conduct for record keeping 2008

Access to Records Policy 2007

9.FULL DETAIL OF POLICY (including results of impact and risk assessments)

Staff will follow the Trust Clinical Policy for record keeping as an overarching policy.

Staff will also follow the Safeguarding policy with regard to record keeping practice to fulfil their responsibilities for their specific area of practice.

These additional guidelines are the specific expectations that apply to our particular area of practice and to our child and family records.

MAINTAINANCE AND MANAGEMENT OF CHILD HEALTH RECORDS

  1. All records must been maintained in a good order.
  2. When records become too copious to be maintained within the normal folder an additional folder should be requested and identified clearly as folder 2 for the same child. These must remain together at all times.
  3. When folders become damaged and in poor condition, replacements must be obtained from the appropriate supplier of the records.
  4. All records must be maintained in the chronological order in which they arrive.

Style of records

  1. Current address label on the outer cover
  2. Inside cover name, signature and designation

Secured to the left:

  1. Significant events page
  2. Tracking page
  3. Demographic information
  4. Health Promotion Programme and transfer summaries
  5. Denver sheet
  6. Growth chart
  7. Index page and continuation sheets for clinical entries

Centrally secured:

  1. Health needs assessment
  2. Individual family members’ health plans
  3. General family information sheet

Secured to the right, in ascending order with most recent at the top.

  1. All other correspondence, safeguarding plans, referrals, family data collection form, etc
  2. Mount sheets

Supplementary/additional records must not be used (for example clinic card records).

All specially identified children’s records should have an over cover in Green for Safeguarding Plans and Orange for Children in Care.

ELECTRONIC RECORDS

  1. Only agreed electronic records may be used.
  2. Security systems and password protection must be identified and maintained. Any breaches must be reported and an incident form completed.
  3. Only authorised users may access the systems identified.
  4. Recorded entries will follow the clinical record keeping principles as identified within this document.
  5. Where electronic systems fail, records must be written within a hard copy of the Child Health Record. Contemporaneous recording is a requirement of our NMC codes and the Trust Clinical Records Policy.

FILING

  1. This is the joint responsibility of all team members.
  2. Letters and correspondence must be dated to acknowledge receipt and read, signed and dated by the caseload.
  3. Test results must be secured appropriately within the correspondence section, either on a mount sheet or chronologically.
  4. Copies of test results must be provided to parents.
  5. Accident and Emergency (A & E) and Minor Injury Unit (MIU) information must be filed securely either on the mount sheet or chronologically within the correspondence section and logged on the significant events page.
  6. Filing of information from Specialist services, i.e. LAC, enuresis, needs to be maintained in a separate section of the record.

TRACER CARDS

  1. These must be used for the safe management and tracking of records within your locally organised systems.
  2. Records removed from a filing system must be replaced by a Tracer Card according to guidelines.

SAFE TRANSPORTATION OF RECORDS

  1. Records will be kept in a locked environment. This may be a locked and secured room, a lockable filing cabinet, or a lockable drawer
  2. Staff must ensure that confidentiality is maintained when transporting records during their daily work.
  3. Records must be locked in the boot of the car and not left in public view.
  4. Only records pertaining to the child/children being visited should be taken into the home.
  5. Staff should not take records home at the end of the day.
  6. In extenuating circumstances when staff are left with records in their possession beyond their normal working day they must inform their manager. These records must be taken to a secure environment overnight and returned the following morning.

CLEAR DESK POLICY

  1. Staff must operate a clear desk policy at the end of each day.
  2. If staff are away from their desk for any length of time records must be returned to a secure and locked environment.

RECORDING INFORMATION

Time

  1. Each entry must have the time of entry recorded by the practitioner in the right hand column alongside the signature.
  2. In addition the time, date and place of the contact must be recorded in the left hand column.

Identification

  1. For the first entry on all new pages practitioners will print their name and designation in full alongside their signature.
  2. Subsequent entries may be signature only.
  3. All staff using the records must complete the signature page at the front of the records.

Abbreviations

  1. No abbreviations other than agreed by the PCT may be used. If long place titles are commonly referred to these may be identified initially in full with the initials in brackets following.

Telephone contacts

  1. Telephone contacts should be recorded.
  2. There should be evidence of analysis of the information, and rationale of action taken. The called should be identified.
  3. Entries should be dated and timed.

SUPPORT STAFF CASE SUPERVISION

  1. Support staff must use the Intervention Paperwork to identify the agreed work to take place with the family and/or child.
  2. All contacts must be recorded chronologically in the main body of the records.
  3. Action planning and goal setting with evidence of progress must be recorded.
  4. Reviews must take place every 4 weeks. Supervision and review with the named Health Visitor/School Nurse must be recorded.
  5. Future plans for the child/family must be agreed.
  6. On completion of the intervention the Intervention Paperwork must be filed in the correspondence section of the record. (Treat as we do for referral paperwork).

PUBLIC PATIENT INVOLVEMENT (PPI) CLIENT’S UNDERSTANDING OF OUR RECORDS

  1. Staff will endeavour at all times to maintain a good level of legibility for the reader.
  2. Staff will adopt the use of Plain English without the use of jargon, and cultural language must be maintained
  3. Plain English must be used for all written information provided for parents, carers and young people.
  4. Records will be written in a culture of openness and honesty with clients.
  5. Staff must contact their line manager with all requests from parents, solicitors or others outside the normal working arrangements for access to child health records. (Ref: Access to Records Policy 2007)

PATIENT IDENTIFICATION

  1. Two patient identifiers must be used on all records. These are full name and NHS number.
  2. Patient Identifiers must be used on each new page of the records and throughout the records to include the mount sheet, growth chart and any additional paperwork that is added that does not clearly identify the child using those specific identifiers.

ORGANISING THE RECORDED INFORMATION

  1. The assessment framework (triangle) will be applied as a minimum at all core programme contacts. Child, parenting and environmental observations will be recorded as per assessment framework.
  2. Date and time of contact and entry must be recorded.
  3. Place of contact must be recorded.
  4. Names and relationship of those present at the contact must be recorded.
  5. Reason for the contact must be recorded, identify if part of the core programme.
  6. Record when an assessment tool is used, eg. Denver, Strengths and Difficulties questionnaire.
  7. Record information and advice provided, both verbally and written.
  8. Record rationale for advice.
  9. Record analysis of the overall observations and identified need.
  10. Record action plan and review.
  11. Record review date and rationale for next contact.
  12. Record evidence of young person/parental agreement.
  13. Use clear headings to identify the critical analysis process and bullet points for the action plan.

PARENT HELD RECORDS (PHR)

  1. PHR are the property of the parent.
  2. The information held in the PHR must be written in line with the directions of the clinical records policy and best practice guidance.
  3. PHR must be written in plain English, free of abbreviations and medical/ professional jargon.
  4. All contacts must be recorded outlining the information and advice provided, and reasons for advice.
  5. Record action plan and next contact.
  6. Record test results.
  7. Provide a copy of referrals where appropriate, and place inside the clear pocket at the front of the record.
  8. Record names of the health team providing care and their contact details in the PHR.

TRANSFER OF RECORDS OUT OF CASELOAD – TO INCLUDE SCHOOL HEALTH

  1. When transferring records an entry must be made in the record stating reason for transfer and draw a line to identify end of care for a particular staff member.
  2. Complete transfer paperwork identifying relevant issues and concerns.

Cross Referenced to:

  • Lone worker policy
  • Transfer of children’s policy safeguarding
  • PCT clinical records policy
  • Data protection
  • Information sharing protocol county wide safeguarding
  • Tracer Card guidelines
  • Incident reporting
  • Records management
  • Access to records policy
  • PPI

10.Monitoring and Performance Management of the policy

Peer audit of records on a twice-yearly cycle

11.Support and Additional Contacts

Network Manager Lead for Records,BolsoverHospital, 01246 283146

Professional Development Lead, Toll Bar House, 0115 931 6195

Records working group

Equality Impact Risk Assessment Forms

Important information about the documentation for Stage 1 Screening and Stage 2 Full Assessment

Please note:

For the purposes of EIRA all Functions, Services, Policies, Procedure and Protocol are referred to as The Process

Stage 1

All processes need to have Stage 1 Screening.

If Stage 2 Full Assessment is found not be required following the Screening, only the Stage 1 documentation should be attached to the process when completed.

Stage 2

If Stage 2 Full Assessment has been identified as needed following the Screening, both Stage 1 and Stage 2 documentation should be attached to the process when completed.

Full guidance on completing EIRAs is available on the Intranet by under Equality and Diversity

Equality Impact Risk Assessment Form (EIRA)
Guideline /  / Service or Practice
Written Policy / Informal policy
Function or Strategy / Informal procedure
Other (please state)

Process being assessed is a:

NB. WHATEVER IT IS BEING ASSESSED WILL BE DESCRIBED AS A PROCESFROM NOW ON

Name of process: Best Practice Guidance for Children and Family Record Keeping

Reference number if an existing policy /process:

Person responsible for process: Alison Higley/ Angela Pogmore

Directorate and Dept section: Children’s Community Health Service

New /  / Existing

Process is

Lead person responsible for conducting the EIRA: Alison Higley /Angela Pogmore

Answer the following screening questions on completion of the assessment and send to the HR Department – Lead for Equality and Diversity for signing off along with a copy of the process.

If no relevance to inequality found

Date screening completed: 18.9.08 / Date for screening review:

If relevance to inequality found and full assessment undertaken

Date full assessment completed:9.9.08
Date for review:9.9.10
EIRA signed off by Trust Equality Lead
Date / Yes / No

Stage 1 –Screening the process

What are you assessing and whom do you need to do it with?

Q1. What is the aim and what are the key objectives of the process?
The aim of the Best Practice Guidance for Children and Family Record Keeping is to outline the processes and responsibilities of staff for recording and managing client information
Q2. What outcomes or benefits is the process attempting to achieve, why and for whom? (e.g. What do you want to be providing, how well, changes improvements and what benefits will there be?)
The benefits to the PCT, staff and clients is that information recorded will be consistent and comprehensive to the agreed format to meet safeguarding directions.
Q3. What other key process does this link with? (Consider process that will affect access to your process and outcomes. Consider a joint EIRA if there are interlinking issues)
The Best Practice Guidance for Children and Family Records Keeping links with Records Policy, PCT’s Data Protection Policy, Confidentiality Policy and the IM&T Security Policy and supports the Information Governance Policy.
Q4. What Partners / Stakeholders (Internal and External) are you involving in this assessment: (Consider the people who developed the process, are responsible for implementing it or are involved in similar or linked process?)
Clinical Records Committee

Is it likely it will be affected by legal requirements on equality?

Q5. Do you believe the process being assessed needs to ensure that it helps to meet the duty of equality in:
Please tick all that apply:
Eliminating Discrimination
Promoting Equal Opportunities
Promoting good relations between different groups
If you ticked any of the above the process will definitely require a full assessment

What do you / we already know?

Q6a Is there any existing EVIDENCE or CONCERN from staff, users or communities that any of the following groups have been or could be affected in different ways by the aims, objectives or implementation of the process? Is that impact positive or negative?
Group / Yes / No / Positive / Negative
Age / 
Gender (Male, Female and Transsexual)? / 
Learning Difficulties / Disability or Cognitive Impairment? / 
Mental Health Need? / 
Sensory Impairment? / 
Physical Disability? / 
Race or Ethnicity? (Including cultural beliefs and norms) / 
Religious, Spiritual belief? / 
Sexual Orientation? / 
Homeless or chaotic lives? / 
Others — Please state
6b.Please give details of the evidence you have:
NMC Codes of Conduct for Record Keeping (2008)
Derbyshire Information Sharing Protocol (2006)

Do you have confidence in not discriminating or impacting on key groups?