News

When it comes to social care, the record business is not exactly glamorous, writes Graham Hopkins. For many workers, making a record comes a long way behind "live" work. They came into social care to work with people - not keyboards or pens. But recording is essential: it's a professional responsibility. But how to do it effectively while making the best use of limited time? A sound guiding principle is to think if you were to pick up a record for the first time, what would make it easier for you to understand the service user and their needs? You'd probably want a personal profile to help gain a sense of the service user. A summary and chronology would put things into a digestible context. And you'd want the rest of the information to be equally accurate, relevant and concise, with each entry signed and dated. Below are the basics you should bear in mind when making records.


Keep up to date
Plan your recording. Ideally you should manage your workload so you can set aside time for recording. If you don't view recording as a priority you will keep putting it off and then miss potentially important information because you are too swamped for time or have forgotten it.

Involve service users
The record should be clear, understandable and respectful to the service user, so write things with them in mind. Indeed, imagine having the service user on your shoulder as you write. You also need to manage the size of the record and its presentation. How would you feel if a file about you was disorganised and shabby with papers falling out? Remember that while a record you're writing is only one of many - for the service user it is their only one. That's a powerful thought to hold on to. Inform service users of their right to read their file and encourage them to contribute and even check accuracy. Indeed, if they read their file, nothing should come as a surprise. Naturally, you should reassure service users that their records - always kept in a safe, secure place - are confidential. And let them know when information is to be shared with others and why.

Distinguish facts from opinion
Be clear what is opinion and what is fact. For example, "There was inadequate stimulation available" is opinion dressed up as fact. That Bobby "lives at 75 Smith Street" is fact; that his house "is untidy and he is unkempt" is opinion (and possibly irrelevant). Opinions - along with judgements, observations, assessments and evaluations - are crucial but must always be substantiated. You must say why you have reached such an opinion - so others can then judge its value.


Only record relevant `
information
Many workers record too much - fearing they might miss something and, if we're honest, to cover their backs. This means records tend to be narrative rather than analytical (see below). However, electronic recording is tending to go to the other extreme and be overly concise. This may be related to weak computer skills or a desire to fit information into a pre-set box - and a feeling that you shouldn't go past the "10 line limit". Deciding what is relevant, however, is a tricky business. A good starting point is to ask yourself: "Why am I including this?" If you can't answer satisfactorily, don't bother with it.

Analyse
Gathering information is one thing and analysing it or making sense of it is something else. This is a much neglected role of recording: it can help you reflect on your practice. It will press you to organise, manipulate and evaluate, which in turn will help keep the record concise and relevant.