1. Why Good Record Keeping is Important
Keeping good records is a very important part of delivering care and support to adults. Care workers should complete daily records of what interventions they have done with the adult, for example whether the adult had a bath in the morning or what they ate for lunch. Records also need to include how the adult is, so their health and wellbeing can be monitored.
Staff should always remember that if there is a safeguarding inquiry or another type of investigation or someone makes a complaint, case records will be used. Staff are responsible for all entries they make in case notes and should remember this when writing their actions and opinions.
Staff should also remember that records can be read by the adult and their family, so it is important that what is written is accurate and respectful.
2. Other Reasons for Keeping Records
Other reasons for case recording include:
- to document the involvement of the service with the adult and the types of interventions that are delivered;
- to inform the adult’s assessment and care and support plan;
- so staff can review and reflect on their work with the adult;
- to identify any patterns in behaviour or risk;
- to document actions taken and not taken, with reasons – so decision making and reasons are recorded.
When making records in an adult’s case notes, care workers should make sure notes:
- are accurate:
- record the views of the adult, in their own words where relevant;
- record facts, that is what happened when;
- in the case of hard copy records – make sure that hand writing can be read, sign and date the record.
Records should be complete, clear, factual and accurate, up to date, confidential and maintain the dignity and confidentiality of the adult.
