155 / Version 1 / Page 1 of 5 / Nov / 2011
Reference: 10/06 / NMC guidelines for records and record keeping July 2007
GSCCC Guidelines
Recording guidance
Introduction
Recording is an essential part of your work. Good, clear recording means that service users get better care. This is because other workers reading about your client will be able to understand the care plan, what care has been given, what works well and the issues they need to deal with. In law, records provide the best evidence or proof that something took place, so you must sign, date and time your records. You must make sure that the meaning of your notes is clear and accurate. Coroner’s court judgements mean that if an event is not recorded then there is no evidence care was ever, actually given (see appendix).
Good recording is a skill that can be developed through practice and reflection, guidance and supervision. This document gives you advice to help you record for Adult Services. The key points are;
· Sign, date and time your entry
· Clearly identify fact and provide supporting evidence
· If an opinion is recorded make sure it is clearly recorded as an opinion
· Make your record personalised and outcome focused
· Make sure the client’s wishes and opinions are included
· Clearly state why decisions are made, how the evidence supports the decision and why the evidence supports the decision
Facts – make it clear you record how you know something happened
Reading a record after events happened can make it difficult to understand. It may not be clear if information is fact or an opinion. So you need to make this very clear. Record what you know and how you know it. Is the event a fact ? did you see it happen ? how did it happen and how do you know it happened ? When ? Where ? Why ? Who ? Provide this information in your records.
If someone else tells you something, then how can you be sure it actually happened ? Is it a fact or is it their opinion ? have they just retold something they believe is true ? Make sure your record provides evidence to prove something actually happened and is a fact. Or if you can’t prove it to be a fact make sure you record the event as someone’s opinion.
Opinions and judgements
Sometimes you will need to record something you didn’t witness and is difficult to prove. You can still record ‘hearsay’ but you must make it clear in your record that there is no proof or evidence it actually happened.
It is important that you clearly record what was said and who said it. If possible, ask people to write down what they say so that you can then use this in your recording. This is especially important if it is a medical opinion. Make it clear in your record who people are. Is ‘Jane’ the client’s mother or the client’s doctor ?
You can include opinions in your recording as long as you clearly say it is an opinion. Starting a sentence with ‘my opinion is…’ is a good way to do this. Say why you believe your opinion. And, where you can, provide supporting evidence. If you are recording someone else’s opinion then the same rules apply. So, ‘Mr Smith’s opinion (brother) is……..’
Focus on the Client
You should keep the client at the heart of the record and care plan. Record information about the individual and their needs, so that your reader can hear the client’s story and account of things. The best way to start is to record what ‘outcomes’ the client wants, so that these can be set as objectives.
Once you know what the client wants, you can identify how this will happen, or which service will work best. Record your assessment and plan - will the client succeed by themselves or will they need help ? what services will help your client ? It is easy to lose track of the client’s needs and change focus to the services the client is receiving. Try to keep the focus of your recording as the person that you are helping.
If you are told anything in confidence then you will need to decide whether you can record this. If in doubt you should speak to your manager about it and they should consult the Adult Services Records Management Procedure.
What outcomes, targets or objectives should look like
These need to be as specific as you can make them. Is the outcome client focused – developing their skills, maintaining their independence or preventing things from getting worse? Try to word the target so that it is positive, rather than negative. Say what the client wants to do rather than what they can’t do. Targets should be SMART – specific, measurable, achievable, realistic and time-bound (this means there is a time limit).
What your record should contain – is it too long or too short ?
Only you and your manager can be clear about how much you should write because this will depend on how complex the client’s case is. Your record should not be too short in case important details are missed, but it should not be too long or important details can be lost. Cut down the length of the record by only including details which are relevant to the care and well-being of the client and their current situation.
You can develop your recording so that all of the right details are included in a clear and concise way. The best way to do this is to read through some of your records from the past. See if you can understand the record and find the important details easily. Or, ask a colleague or your manager to go through this with you.
Your recording should have enough details in to avoid the client having to tell their story again to each new carer they see.
Peer review, reflective practice, supervision.
It is easy to be defensive over the quality of what you have recorded, especially if someone appears to criticise it. However, opening up your recording for others to read and comment upon can be the easiest way to improve your skills. If you have time and your manager agrees, then get a colleague whose opinion you value to read a sample of your records and ask them to comment on them. What was good? Are there things that can be improved?
Managers should review a sample of recording as part of the supervision process.
Confidentiality
Remember that what you know about clients is confidential. Only share information with staff involved in caring for the client or with people the client has consented can know these details. You may disclose information to others only if you believe someone is at risk of harm.
Appendix to the Guidance – further information which may be useful
Things to think about in your recording?
· consider using ‘I’ to describe the client rather than their name or ‘they’. This is a really simple way to change the way you write. It helps you to record your clients wishes and care needs and will improve the connection between them and readers.
· check that other carers and staff can understand what you have written
· Be willing to accept constructive criticism of your recording, understanding that this will improve quality. You could read other people’s recording and take good practice from them to use in your own work.
· Write information that tells people what they need to know. Write in clear, concise, precise text. This can be hard. Taking the time to do this will make it easier for other people to understand.
· Write the document in clear English, but don’t use slang, or abbreviations.
· Write to express what you know or what needs to be done. Remember that some people working for Adult Services are using English as a second language.
· Keep sentences short and to the point.
· Ask questions in the record, if needed.
· Describe precisely and fully where necessary. Words like ‘large’ mean different things to different people. ‘A large gap at the back of the minibus’ should be replaced by ‘a 3m gap’ and so on.
A simple way to think of your document is to try the coffee cup test. Imagine reading out your record over a cup of coffee with the client, or their representative, or a carer. If the text doesn’t sound like the words used in a real conversation then your text will probably be difficult to read and understand.
Data Protection Act and information security
You need to understand that there are rules about what information is recorded, how that information is recorded, for how long it is kept and who the information can be shared with. Hampshire County Council and Adult Services provide guidance on Data Protection and Records Management Procedures. The GSCC Code of practice and the Nursing and Midwifery Council also provide guidance.
Appendix to the guidance – making judgements
Which of these examples is fact and which is opinion ?
Are the following statements fact or opinion ?
· Mrs F is incapable of handling her finances.
· This is the first incident of abuse.
· I saw Mr V going up the stairs unaided.
· Mrs P is making good progress.
· Mr C said he was certain that his daughter has taken the book.
Examples of Positive Objectives
Mr C wants to move around the home safely and independently. Objective – Mr C to walk around the home, using a Zimmer frame and to go up and down stairs using a lift by the end of October.
Mrs G needs help to wash and dress. Objective – Mrs G to shower daily and dress with the help of one other, with the opportunity to choose her own clothes.
Mrs K needs to come to terms with the death of her husband. Objective – Mrs K to have the opportunity to talk about feelings following her husband’s death.
Mr Y needs to get in and out of the bath. Objective – Mr Y to bath every other day using a hoist assisted by two others.
Examples of what other organisations say about recording.
The Nursing and Midwifery Council Standard of Conduct gives these instructions;
• You must keep clear and accurate records of the discussions you have, the assessments you make, the treatment and medicines you give and how effective these have been.
• You must complete records as soon as possible after an event has occurred.
• You must not tamper with original records in any way.
• You must ensure any entries you make in someone's paper records are clearly and legibly
signed, dated and timed.
• You must ensure any entries you make in someone's electronic records are clearly
attributable to you.
• You must ensure all records are kept securely.
The General Social Care Council Code of Practice includes the need to ;
· Communicate in an appropriate, open, accurate and straightforward way
· Respect confidential information
· Maintain clear and accurate records
Other information in Adult Services that links to recording
The SWIFT manual
The Residential, Nursing, Day Care and Community Response practice manual