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8.1.1 Recording Principles

SCOPE OF THIS CHAPTER

The following guidance is intended to ensure the security of case records and the integrity of the information that they contain.

For Council staff seconded to Health, please see also the Sussex Partnership NHS Foundation Trust Policy for the Management of Integrated Health Care Records.

RELATED CHAPTERS

Retention and Destruction of Records Procedure

Records Disposal List Procedure

Records Disposal List Template

Record Management Procedure

AMENDMENT

This chapter was updated in April 2015.


Contents

  1. Introduction
  2. Records Must be Kept on all Individuals Referred
  3. Anti Discriminatory Recording Practice
  4. Individuals Must be Informed About Their Records
  5. The Practitioner Primarily Involved Should Complete the Record
  6. All Relevant Information Must be Recorded
  7. Individuals Should be Involved in the Recording Process
  8. Case Record Documents Should be Copied to the Individuals Concerned
  9. Information About Individuals Should Normally be Shared With Them
  10. Records Must be Legible, Signed and Dated
  11. Timescales for Recording
  12. Records Must be Written in Plain English and Prejudice Must be Avoided
  13. Records Must be Accurate and Adequate
  14. Managers Must Oversee and Monitor all Records
  15. Records Should be Kept Securely
  16. Removal of Records Must be an Exceptional Occurrence
  17. Records Moved to a new Location Must be Monitored
  18. Case Closures
  19. Records Must Usually be Retained After Closure
  20. Use of Computers Outside the Workspace


1. Introduction

Good quality case recording is essential in ensuring:

  • 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 service users - see Mental Capacity Act 2005 Policy and Practice Guidelines;
  • 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;
  • Adequate information for staff and managers working to ensure the best possible utilisation of available resources;
  • Ensure that people receiving services and carers with specific communication needs are supported to contribute to and access their records and key information.


2. Records Must be Kept on all Individuals Referred

Each individual must have his or her own case file from the point of Initial Contact: records must be recorded on CareFirst or the appropriate electronic recording system in the agency or organisation where the practitioner is based or to which they have been seconded; audio, video or paper recordings may also be kept.

Case records must be organised so as to safeguard their contents, protect the confidentiality of the individuals concerned, and make them as easy as possible to use.

Information held in electronic records must accurately reflect any corresponding information recorded within paper files.

Records held on paper may extend to more than one volume. Where more than one volume exists, the dates covered by each volume must be clearly recorded on the front cover.


3. 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.


4. Individuals Must be Informed About Their Records

Individuals have a right to be informed about the records kept on them, the reasons why, and their rights to confidentiality. Individuals must also be informed of their right to look at all records that relate to them.

See Confidentiality Principles.

Information must be provided in a form that individuals will understand - in their preferred language or method of communication. An interpreter should be provided if needed.


5. The Practitioner Primarily Involved Should Complete the Record

The practitioner primarily involved, that is the person who directly observes or witnesses the event that is being recorded or who has participated in the meeting/conversation, must complete records.

Where this is not possible and records are completed or updated by other people, it must be clear from the record which person provided the information being recorded. Preferably the person with first hand knowledge should read and sign or endorse the record.

Records of decisions must show who has made the decision and the reasons for which it has been made.


6. All Relevant Information Must be Recorded

Every case record must be completed with basic information about the individual's full name, date of birth, identification number, any risk assessment and a transfer/closing summary (where appropriate).

The record should capture whether the person has:

  • Communication needs e.g. requires an interpreter or information provided in different formats; or
  • Substantial difficulty engaging with care and support planning processes and therefore needs an appropriate person or independent advocate to support them.

In addition, the record should contain information relating to the individual's mental capacity, any Advance Decision to Refuse Treatment, Lasting Power of Attorney, Enduring Power of Attorney or Independent Mental Capacity Advocate.

Entries related to assessments (including about mental capacity) should summarise the analysis of assessment data that has taken place, with the reasons for resulting eligibility decisions stated clearly.

Entries relating to resources allocated and services specified in Support Plans should consistently refer to the objectives specified in the plan, and the achievement of outcomes.

Projected and actual costs of resources allocated must be consistently recorded in the Care and Support Plans and elsewhere. The Care & Support Plan should be authorised to confirm that the plan meets the eligible needs of the person and the use of the funding is legal.


7. Individuals Should be Involved in the Recording Process

Individuals must be routinely involved in the process of gathering and recording information about them. They should feel they are part of the recording process.

They should be asked to provide information, express their own views and wishes, and contribute to assessments, reports and to the formulation of plans.

Where they have the mental capacity to do so, individuals should be asked to comment upon and sign assessment and review forms. They should also be given copies of any care plans that relate to them.

The records should include the individual's own words as to their current issues, needs and proposed solutions; any recent life events, relationships, health issues; and any environmental factors that affect their needs.

Generally, they must also be asked to give their agreement to the sharing of information about them with others and any sharing limitations should be recorded. The consent to share information should be reviewed during any assessment to ensure that previous agreements reflect the person’s current wishes.

Where individuals lack mental capacity, practitioners should consult with and involve carers, family members and friends who take an interest in the welfare of the individual, i.e. they should be asked to sign the assessment form and be provided with copies of relevant documentation.

Where an unsupported person who lacks capacity is concerned, a decision may be required for serious medical treatment or a change of accommodation, in which case a referral for the appointment of an Independent Mental Capacity Advocate (IMCA) may be required. Where appointed, the IMCA should be consulted and involved in the assessment process - see Mental Capacity Act 2005 Policy and Practice Guidelines.


8. Case Record Documents Should be Copied to the Individuals Concerned

The maximum amount of information concerning an individual's care should be made available to him/her and to his/her carers as appropriate. Where there is uncertainty about the sharing of such information, staff should consult with supervisors.

In general, the following documents should be routinely shared with and copied to individuals and their carers, attorneys and advocates:

  • Assessments/re-assessments of individual's needs, including an eligibility determination;
  • Assessments of carers (including combined assessments);
  • Support Plans;
  • Review forms;
  • Vulnerable Adults investigation meeting minutes and reports.

In relation to Independent Mental Capacity Advocates (IMCA), where appointed, their right of access to all relevant information only lasts during the period of their involvement, and once their involvement ends, they withdraw from the case and their right of access will end.

Other items to be shared are:

  • Access to Records leaflet;
  • Complaints Leaflet;
  • Service brochures and leaflets;
  • Information on charging policy.


9. Information About Individuals Should Normally be Shared With Them

Information obtained about individuals should usually be shared with them unless:

  • Sharing the information would be likely to result in serious harm to the individual or another person; or
  • The information was given in the expectation that it would not be disclosed; or
  • The information relates to a third party who expressly indicated the information should not be disclosed.

Where information is obtained and recorded which should not be shared with the individual concerned for one of the above reasons, it should be placed in the confidential section of the record and a note of the reasons, should be recorded.

See also Leaflet 'What you need to know".


10. Records Must be Legible, Signed and Dated

Those completing computerised records must show their name and the date when the recording was completed.

If possible, manual records should be typed or handwritten in black ink and all records must be signed and dated.

Any handwritten records must be produced so that readers not familiar with the handwriting of the writer can read the records quickly and easily.

It must be possible to distinguish the name and post title or status of the person completing the record. If there is any doubt of the identity of the writer from a signature, the name should be printed.


11. Timescales for Recording

Wherever possible, records of Initial Contacts should be completed by the end of the day in which it is taken or as soon as possible on the next working day.

Case record entries related to investigations of alleged abuse and neglect must be recorded within two working days; where such allegations are taken over the weekend, entries will be made to the case record on the following Monday.

Otherwise, case recordings, for example those related to assessment, care planning, resource allocation, monitoring, and review activity should be updated as information becomes available or as decisions or actions are taken or as soon as practicable thereafter.


12. Records Must be Written in Plain English and Prejudice Must be Avoided

Records must be written concisely, in plain English, avoiding statements that are judgmental or speculative, and focusing instead on facts about the needs, strengths, and objectives of individuals.

Entries to case records should be written in a culturally competent manner, sensitive to differences of diverse ethnic and religious backgrounds and lifestyles - see also Section 2.2, Anti Discriminatory Recording Practice.

Use of technical or professional terms and abbreviations must be kept to a minimum; and if there is likely to be any doubt of their meaning, they must be defined or explained.


13. Records Must be Accurate and Adequate

Care must be taken to ensure that information contained in records is relevant and accurate and is sufficient to meet legislative responsibilities and the requirements of these procedures. This will include details of the assessment of an individual's mental capacity see Mental Capacity Act 2005 Policy and Practice Guidelines.

Every effort must be made to ensure records are factually correct.

Records must distinguish clearly between facts, opinions, assessments, judgments and decisions.

Records must also distinguish between first-hand information and information obtained from third parties.


14. Managers Must Oversee and Monitor all Records

The overall responsibility for ensuring all records are maintained appropriately rests with managers with day-to-day responsibility, delegated to other staff as appropriate.

The manager should routinely check samples of records to ensure they are up to date and maintained as required and, if not, that deficiencies are rectified as soon as practicable.


15. 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.

Paper records will be kept in folders with all documents firmly affixed to prevent their loss. They should normally be stored in a locked cabinet, or a similar manner, usually in an office which only staff/carers have access to. Records should not be left unattended when not in their normal location.

Each team will have a method in place to ensure that the location of all records is known at all times, and that they are returned to filing cabinets in accordance with this policy.


16. Removal of Records Must be an Exceptional Occurrence

Paper records should not normally be taken from the location where they are normally kept.

If it is necessary to remove a record from its normal location, a manager should approve this and should stipulate or agree how long it is necessary to remove the record. File details must be entered on CareFirst or the appropriate electronic recording system in the agency or organisation where the practitioner is based or to which they have been seconded. The manager must also be satisfied that adequate measures are in place to ensure the security of the record(s) whilst they are removed. For example, records must never be left in unattended vehicles.

The authorisation for a record to be removed must be recorded and those who may have need to see the records should be informed of their removal. The manager must then ensure the record is returned as required/agreed.


17. Records Moved to a new Location Must be Monitored

Where paper records are moved to a new location, the date of transfer should be clearly recorded. The sender should check that the records have arrived at their intended destination. File details must be entered on CareFirst or the appropriate electronic recording system in the agency or organisation where the practitioner is based or to which they have been seconded.

Click here for Record Management Procedure.


18. Case Closures

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.

Any paper records should be integrated and secured in the closed section of the filing system.

The electronic record should be updated and the closure date logged.


19. Records Must Usually be Retained After Closure

Records should be retained for the period agreed in Brighton and Hove's archiving and destruction guidance or, in relation to practitioners based in or seconded to other agencies or organisation, the guidance agreed by that agency or organisation.

Click here to link to Deepstore.


20. Use of Computers Outside the Workspace

Staff must not use their personal computers for council business unless they have a Citrix account which enables them to connect to the Council systems via a secure route.

Staff may work from home using a council encrypted secure Laptop, i.e. one that has been issued. However, wireless connection must not be used unless Wi-Fi Protected Access (WPA) encryption solution is in place.

End