RELATED CHAPTERS

Information Security Policy

Information Sharing and Confidentiality Procedure

Customer Access to Records Procedure

AMENDMENT

This chapter was amended in June 2014. Section 5, All Case Work Activity Should be Recorded and Section 14, Professional Language have been amended as a result of local review and should be re-read.

1. Introduction

Case recording should be clear and accurate.

High quality case recording is necessary to achieve high standards of practice and the best possible outcomes for people who use our services.

Case records should:

  • Reflect the key principles underpinning best practice in case recording of openness, partnership, and accuracy;
  • Be of a consistent professional standard;
  • Demonstrate sound social care practice, in line with the Service’s policies and procedures;
  • Fulfil requirements set down within the wider legislative and best practice framework.

2. Purpose of Effective Record Keeping

Good quality case recording is essential in ensuring:

  • There is a documented account of the local authority’s involvement with each customer or carer;
  • Continuity of service to individuals when staff are unavailable or change, or when a service resumes after a period of time;
  • Effective risk management practices to safeguard the well-being of individuals in receipt of services, especially in emergency situations;
  • Clarity of the assessment process and decision making in relation to the mental capacity of all customers – see Mental Capacity Act 2005 and Mental Capacity Act 2005: Policy and Practice Guidelines (Including Mental Capacity Assessments);
  • Effective partnerships between staff, individuals, their families and carers, and other providers;
  • Clarity of information for everyone involved in the planning and delivery of services, and in the event of investigations, inquiries, or audits;
  • Providing adequate information to support the performance, planning and commissioning functions of the service.

3. Keeping Customers Informed about Recording

  • Customers and carers have a right to be informed from the outset that case records will be kept and the reason why, their rights to confidentiality and the limits of this, and their rights of access to their records;
  • It should also be explained to them how they will be involved in the process of gathering, recording and checking the accuracy of information. Wherever possible, records will be made with the person present and directing the content. ‘I’ statements should be used, for example ‘I did this and this is what I think about it.’ These can be supported by the opinions of supporting staff which must be clearly differentiated from the customer’s views.

The customer’s and (when appropriate) carer’s authorisation to share information with third parties should be sought at the start of the involvement with them so that they understand the circumstances in which the information sharing will occur and the reason why this is important. This should then be recorded.

4. Anti Discriminatory Recording Practice

The Council’s commitment to equal opportunities and anti-discriminatory practice should be demonstrated in all case recording practices. All staff should:

  • Be aware of and respect differences of opinion and experience that may be expressed by people receiving services and carers;
  • Be sensitive to the differences in culture, language, ethnicity, race, gender, disability, sexual orientation, religion and sensory impairment when recording;
  • Be aware of and avoid using stereotypical language; all records should be written in a way that shows respect;
  • Ensure that customers and carers with specific communication needs are supported to contribute to and access their records and key information.

5. All Case Work Activity Should be Recorded

Records should include:

  • The name of the worker allocated to the customer and other agency representatives involved in the customer’s care listed prominently on the first page of the record;
  • All incoming and outgoing telephone calls, including attempts made to contact the customer or other relevant persons should be referenced in the main body of the record but held in the section for third party information;
  • All incoming and outgoing correspondence should be referenced in the main body of the record but held in the section for third party information. This should include:
    • Leaflets / information sheets;
    • Details of records that have been offered or shared.
  • All meetings held with, or in relation to, the customer or carer should be referenced in the main body of the record with minutes held in the section for third parties. This is because there may be some information discussed in meetings which cannot be shared with the customer because it is deemed sensitive under the Data Protection Act 2018 or the Mental Capacity Act 2005. If this is the case, the information should be clearly identified within the minutes;
  • All reports or documents produced as a result of work with the customer and / or carer;
  • Case summaries to be completed periodically and in times of significant activity and prior to case transfer or case closure.

6. Chronological Order

  • Record casework activities in the order they took place;
  • Record the date and time the activity took place, not when it was inputted to Carefirst.

7. Concise and Relevant

  • Provide a clear and concise account of all significant aspects of the work undertaken;
  • Consider the purpose of each case record and record proportionately;
  • Include the outcome and / or action planning statements.

8. Accurate

  • Ensure that all information is recorded accurately and kept up to date;
  • Clearly distinguish between fact and professional opinion:
    • Link fact with evidence;
    • Only record unsubstantiated or unattributable information if it is judged to be of current or possible future significance and make it clear that the information is unsubstantiated. Check the accuracy as soon as possible and record the extent to which statements have been verified.

9. Reference Sources of Information

  • Identify all sources of information and contributions to assessments, support plans and other case records;
  • Identify quotations by using speech marks and attribute to the source;
  • Include the name and job title of the author in every record;
  • When information has been received from a person who wishes their identity to be withheld from the customer, record their details in the confidential section of the case record.

10. Analysis

When appropriate, ensure case records contain a component of analysis and show more than a description of events and circumstances. Demonstrate:

  • That information is evaluated and its relevance, accuracy and weight assessed, wherever possible in agreement with the person giving the information;
  • The practitioner, customer or carer’s ‘thinking’ about what exactly is happening and why.

11. Decision Making

Record all decision making, demonstrating:

  • The reason for the decision and who was involved;
  • What information/evidence was taken into account?
  • All agreements made and any disagreements that arise, including their resolution.

12. The Views, Preferences and Wishes of Customers and Carers

This is a central theme underpinning all case recording. Customer and / or carer views must:

  • Be evident in case records and related to the sequence of decisions taken and arrangements made. Wherever possible, case records should be recorded in the customer’s own words and from their point of view;
  • Use the customer’s or carer’s own words where possible;
  • Show the outcomes that they want to achieve.

13. Accessible

Information contained in case records must be accessible to those who need it:

  • Follow procedures outlining where information should be recorded;
  • Highlight and draw attention to important information.

14. Professional Language

  • All case records are formal. The style of written language should always be courteous and in plain English, but informality and over familiarity should be avoided:
    • Address customers and carers in correspondence by Dear Mr Taylor, or Dear Brian.  It is never appropriate to use Hi Brian;
    • In case records, address customers and carers by their title and surname.
  • Always use plain language that will be easily understood by all audiences, including the customer and / or carer.

15. Writing in the First, Second and Third Person

If possible, record assessments in the first person, from the customer’s point of view, for example ‘I find it difficult to climb the stairs which means I can’t get to the bathroom easily. This causes me problems with continence and with keeping myself clean.’ Where assessments contain the worker’s analysis, it should be made clear that it is the worker’s view.

Write all case notes in the first or third person, as appropriate. Please see the examples below:

  • 1st person Mrs Brown said “I have arthritic pain in both of my knees all of the time”;
  • 2nd person You told me that you have arthritic pain in both of your knees all of the time;
  • 3rd person Mrs Brown reports that she feels arthritic pain in both of her knees all of the time.

If the customer is able to direct their own case recording, this should be encouraged and enabled, and the record should reflect this clearly. It would then be written in the first person as the customer would be outlining what happened and how they felt about it. The worker should also record their own view, but it should be made clear which parts of the case record come directly from the customer and which come from the worker.

16. Management Oversight

Managers have overall responsibility for ensuring all records are maintained appropriately.

Managers and / or senior practitioners must demonstrate their oversight of case work practice by recording ‘Managers Decisions’ in CareFirst.

Achieving high standards in case recording practice requires monitoring and quality assurance arrangements. Case recording activity should be monitored:

  • Through supervision (see also Staff Supervision Policy);
  • At the point of case closure and / or transfer;
  • Through case file audit.

17. Case Closure

Cases may only be closed with the agreement of the line manager. Agreement will be given where needs have changed and the individual is no longer eligible for services.

When cases are closed the reason for closure and evaluation of the success or otherwise of the objective for the case should be recorded.

18. Records Should be Kept Securely

All records must be kept securely.

In order to keep electronic records secure, staff should not share their passwords and should lock their computers when away from their desks.