How to make records

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.