It is difficult to overstate how important good record keeping is yet it is surprisingly rare. Good record keeping ensures that relevant information is captured for use by carers and other professionals. That information may be needed for a variety of reasons including, among other things:
• Identifying trends for use in risk assessments.
• Monitoring changes in medical conditions such as diabetes and hypertension.
• Providing evidence that appropriate care is being delivered.
All too often we see care records that use short hands such as ‘all care given’. A rule of thumb that carers may find useful is ‘if it isn’t recorded, it didn’t happen’. All care, all responses to particular incidents, all discussions with professionals and other stakeholders – anything at all that is done or said about a service user – MUST be recorded.
Poor record keeping generates serious risks. First, and most importantly, service users are potentially at serious risk if important information is not captured and communicated effectively. That can lead to anything from failing to identify service users’ lifestyle preferences to mistreating medical conditions in a life-threatening way.
There is, however, also a serious risk to carers and other professionals of poor record-keeping. In any investigation into the treatment of a service user, for example a safeguarding investigation or a compliance review by the Care Quality Commission, the care plan is the first document that will be looked at. Applying the rule of thumb identified above, investigators will be very slow to accept that appropriate action was taken if it was not contemporaneously recorded. Those with professional registrations, such as nurses, also risk disciplinary action if they fail to meet professional standards about record keeping.
What, then, are the keys to good record-keeping? The following are some useful tips:
- Assume that the person reading your notes has no previous knowledge about you or the service user in question. The more detail the better.If you find yourself too busy to make full notes, the service is understaffed. Raise the issue with your manager and if that doesn’t resolve matters, consider using the whistleblowing procedure.
- Keep a record of your efforts. Ensure that you don’t take the fall for a service being under-resourced.
- Seek and exploit training opportunities. Record-keeping is a skill which is learned and professional training can be a great help.
- Seek support from managers and colleagues if necessary. This is especially important for new entrants to the care sector, those who do not speak English as a first language and anyone with dyslexia or literacy difficulties.
Writing reports requires even more care as they are bound to be scrutinised carefully. Senior management or legal advice should be sought in appropriate cases.
In a nutshell, when it comes to record-keeping be thorough and seek help if you need it.