KEY POINTS

  • Effective and timely case recording is pivotal to the work of Adult Care. It is vital to our customers and the integrity of our practice both individually and as an organisation.
  • Recording should be done in a way that captures the thoughts, feelings and wishes of the individual, alongside those of their family members or carers.
  • As a broad principle, there should be a record to show how decisions that affect a person’s life were reached.
  • It is essential in recording to give enough information to show what was known at the time and what it was considered to mean. Where decisions are made these should always be recorded.

December 2018: This chapter has been revised as a result of local review. In particular, Section 3, Recording Conversations is new.

1. Introduction

All Adult Care staff recording in customer records should read the Adult Care Recording Guidance.

Effective and timely case recording is vital to the integrity of our practice. It provides the evidence base for our customers’ experience of Adult Care. This includes the basis of any decisions made, determination of eligibility for support, our compliance with our statutory duties, capturing outcomes, and measuring the effectiveness of our involvement in people’s lives.

Our recording practice is subject to scrutiny from a number of sources:

  • all customers have access to their records through the subject access process;
  • cases giving rise to complaint will be subject to rigorous review by managers, independent reviewers or auditors and potentially the Local Government and Social Care Ombudsman;
  • increasingly, more complex cases may require legal oversight and our case recording will become integral to court proceedings;
  • quality assurance measures include regular audits of case work evidenced in customer records;
  • cases may be subject to critical or serious case review.

2. General Principles

The council is committed to achieving the highest possible standards of recording, maintenance storage and sharing of high quality records.

In production of these records, the organisation will:

  • ensure a person centred approach to all recording;
  • ensure case recording policy and procedures for record maintenance are consistently applied;
  • ensure recording assists high quality planning and case management to enable the protection and wellbeing of people;
  • ensure Information Sharing Policy and Guidance are adhered to by all employees;
  • maintain documentary evidence of Adult Care’s involvement which will allow auditing of performance;
  • update and revise policy statements to ensure compliance with legislation and good practice.

This will help to ensure that:

  • case records are maintained for all people we support;
  • clear standards are specified for monitoring, auditing and supervision processes, roles and responsibilities;
  • recording is timely, accurate and up to date;
  • in all recording, a distinction is made between fact and opinion;
  • recording reflects and is sensitive to culture, ethnicity, gender, disability, age, sexual orientation and the religious belief of the person being supported;
  • people are informed of their rights and given appropriate access to their records;
  • policy reviews, induction, auditing, supervision and training will ensure high quality practice in recording and maintaining a person’s record;
  • appropriate storage and filing of information will ensure the safety of sensitive and confidential information and compliance with data protection requirements.

3. Recording Conversations

In recording, it is important to demonstrate that a conversation has been understood, not to simply provide a list of information.

Recording should be done in a way that captures the thoughts, feelings and wishes of the individual, alongside those of their family members or carers.

Good recording underpins, supports and demonstrates:

  • person-centred focus;
  • outcome-focus;
  • partnership working;
  • involvement and empowerment;
  • increasing choice and control;
  • good decision-making;
  • risk enablement;
  • continuity, consistency and equality.

If not carried out effectively recording can be disempowering, for example, if it labels or stereotypes people, undervalues their concerns, or pushes them into boxes. To avoid disempowering, or disrespectful recording, write as if the person was looking over your shoulder, or reflect back on what you have written asking, ‘How would I feel if that was written about me?”.

Recording takes time, and getting a proportionate amount of relevant information recorded is key. The amount recorded should relate to the complexity of the situation, for instance depending on:

  • how clear the person’s views, wishes and preferences were;
  • how much was going on;
  • how much things changed (or will change in the future);
  • how much risk there was (or will be in the future);
  • how much dispute there was (or will be in the future).

As a broad principle, there should be a record to show how decisions that affect a person’s life were reached. That means that in assessment we need to record:

  • what information we gathered, from whom and why;
  • what we thought it meant and why;
  • our judgement based on what we thought it meant.

This then leads into the decisions about what should happen and a record that these actions have taken place. Hindsight bias means that people tend to think afterwards that what happened should have been foreseen. It is therefore essential in recording to give enough information to show what was known at the time and what it was considered to mean.

Where decisions are made these should always be recorded. It should be possible to track the process of decision including knowing who was involved, the rationale or evidence on which the decision was based and ultimately who made the decision. There should always be sufficient information for the decision to be defensible.

It can be useful to consider Rolfe’s Reflective model (2001) in order to support succinct and proportionate recording as described above.

 

Adapted from Rolfe et al (2001) Critical reflection in nursing and the helping professions: a user’s guide. Basingstoke: Palgrave Macmillan.

Ripfa 2018: Ripfa tips on recording

4. Quality Practice Standards and Audit

The Adult Care Quality Practice Standards set out what good case work should look like and include the key things that we expect to see evidence of when we review our case work. The Quality Practice Audit process is a continuous programme of auditing activity, primarily undertaken by supervisors and line managers. Audits are intended to be a tool to support reflective supervision by focusing on a more in depth exploration of practice against a particular case. Audits are intended to support continuous professional development, and to affirm and enhance the professional capability of practitioners.

The process for undertaking Quality Practice audits and their contribution to individual and organisational development is detailed in the Quality Practice Audits.

Each individual standard is detailed in Quality Practice Standards.