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For the record Accuracy and detail are key for providers, says Jenny Wilde. It is difficult to overstate how important good record-keeping is within health and social care settings. 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: • identifying trends for use in risk assessments • monitoring changes in medical conditions • providing evidence that appropriate care is being delivered All too often we see care records that use shorthands 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. 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. The CQC will rely heavily on records during inspections and will not hesitate to criticise a service that shows flaws in its record-keeping processes. Jenny Wilde is director at Ridouts Solicitors

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