The record business

An important challenge for managers and practitioners in social care is to record the work done with clients. Being people-focused, social care workers feel that once the work is done then recording it is a lesser priority -Ênot least given that the next urgent piece of work is already in pressing need of attention.

A good starting point is winning staff to the purpose of recording. If you can do this, it is more likely to be done and to be of a good quality. Even in an established team this is worth reviewing as often recording becomes sloppy or does not keep up with changes in cases.

So why bother recording? Well, we have to for a start. Records are required as a matter of law as well as a matter of good practice. What’s written down provides a permanent record of events that have happened and this is important for several reasons. Case records can:

• Focus the work of your organisation.
• Support effective partnership with clients.
• Help with continuity.
• Provide an essential tool for managers to monitor work.
• Provide evidence for investigations and inquiries.

For practitioners, case recording provides the history of your organisation’s intervention in a person’s life. It can be used to evaluate the success of past interventions and help shape future ones. It provides a chronology to consider the impact of significant life events and a record of the work caseworkers have done.

For managers, case recording can help with disputes about who agreed to what, and provide evidence of co-operation or otherwise. Of course, management recording takes other forms as well: supervision records, review and management meetings and action plans. All these records map our daily working lives and provide evidence that we are worth our salaries.

For clients, their case record may be the only means they have by which to make sense of their past and they deserve an honest, thorough and professional account of events of which, at the time, they may have had little understanding.

So, impress upon your staff: records are an integral part of good care practice. However, to record is one thing, to record well quite another. Here are a few practical things to think about.

 Be clear about the purpose of the record – know why you are keeping it.

• Know where you are going to record it.
• Make clear what is factual information, direct observation, understanding, hearsay, opinion, judgement, assessment, evaluation and commendation.
• Be accurate, relevant and concise while still providing a complete record.
• Be clear what you are going to write.
• If recording manually, write legibly in ink. Do not use correction fluid. If you cross something out make sure that it can still be read.
• Use plain and respectful language.
• Sign and date each piece of recorded information, including messages.
• Be aware of confidentiality and understand the law on access to information and data protection.
• Indicate who or where the information has come from.

As always, staff need to be aware of the needs of their audience, which must include the service user as well as you the manager and other professionals. By considering the audience’s language skills, and knowledge and understanding of the subject, this should help in pitching it right.

And why not check the accuracy of your record with the service user, if appropriate? As the Social Services Inspectorate says in Recording with Care: “You need to give clear guidance and training to staff about working in partnership with service users and carers and constructing and sharing written records. Gaining clearance to share third-party information with service users in day-to-day work is important in ensuring that access is maximised.”

If recording is timely, it will be much more accurate and easier to produce. So, try to make sure staff working patterns allow time for writing up immediately after events – or as soon as possible afterwards. To inspire the overall quality of recording, an audit of records is useful in identifying common difficulties or shortcomings, as well as good practice.

In keeping records it is always worth asking whether a file note should rather be a letter. By asking this question you challenge yourself to become much more open in your recording, creating a shared record rather than a record reflecting only the record keeper’s version. It is this latter approach that has led to open access being so traumatic -Êwhen service users see what has been said about themselves or their families, for example. And a complaint from a disgruntled client (with a legitimate axe to grind about inaccurate or defamatory notes) tends to focus the mind on the need for good recording.

Some managers may lament that newly qualified workers “don’t know how to record”, and it may be true that academic courses enhance essay-writing skills at the expense of case recording skills. But we all had to start somewhere, and new staff, or staff unpractised in case recording will need guiding and tutoring. Recording is a skill and, as with all skills, can be improved through practice. And we all know what they say about practice.

Christine Doorly is regional director of the National Care Standards Commission; Sheena Doyle is an independent social care consultant.

 “When I was…

“Head of an inspection team we developed a dictionary of stock phrases and paragraphs for situations we encountered frequently. This enabled the recording that needed more thought and attention to be done in a considered way. Efficiency of recording increased significantly as a result.” (Christine Doorly)

Top tips

• Record as soon as possible after an event for accuracy and good recall.
• Back up your files if recording electronically.
• Imagine the service user looking over your shoulder while recording.

Rubbish tips

• The more you write the more it appears to others that you work hard. (Actually you look like someone who spends too much time in the office.)
• Because of access to records it is best to write as little as possible.
• Record everything to be on the safe side.

Resources

2 Liz O’Rourke, For the Record- Recording Skills Training Manual, Russell House Publishing, 2002, price £41.45. Visit www.russellhouse.co.uk

3 For an excellent website on effective recording in children’s services, visit www.writeenough.org.uk

4 Graham Hopkins, Plain English for Social Services, Russell House Publishing, 1998