Effective Care Records

Summary

·        The quality of records is key to effective service provision

·        Make records contemporaneously

·        Link records to care plans and risk assessments

·        Pay attention to punctuation and grammar

·        Record the facts

It has long been accepted that “if it is not recorded then it didn’t happen”, the converse of this is also true, if it is recorded then it must have happened. The quality of records made by social care providers is a vital aspect of evidencing that people’s needs are met and that associated risks are managed. Yet, despite this many services are criticised for the quality of the records made by care and support staff. Some examples of poor-quality recording include:

“care plan followed no concerns all secure on leaving” - this is a typical recording made by a home care worker, the problems with this record are:-

1.      It does not evidence how the service user was involved in their care

2.      It does not provide any information about whether needs or outcomes were met

3.      It does not provide any information on the service users' wellbeing

4.      The “no concerns” statement is merely a subjective opinion made by the worker

5.      There is an absence of punctuation

6.      The premises cannot be “secure on leaving” if the worker has not yet left

7.      There is no evidence of what was “secure”

8.      There is nothing that can be used in care plan reviews

9.      There is no information about how risks have been managed

“X was asleep when I came on shift got up at 9am T+T for breakfast sat in lounge” – this is a typical recording made by a care home worker, the problems with this record include:-

1.      It does not evidence how the service users was involved in their care

2.      It does not provide any information about whether needs or outcomes were met

3.      It does not provide any information on the service users' wellbeing

4.      There is an absence of punctuation

5.      There is nothing that can be used in care plan reviews

6.      There is no information about how risks have been managed

7.      The record is about the care worker “X was asleep when I came on shift”

8.      Who got up at 9am?

9.      What does T+T for breakfast mean?

10.  What did the service user do when they sat in the lounge? Did they want to sit in the lounge? Did they need pressure-relieving equipment? How long did they sit in the lounge?

11.  The record was clearly made at sometime late in the morning and covered a period from the workers start of shift to after breakfast.

12.  There is no evidence that the service user chose T+T and whether this was consistent with their nutritional needs, or even if they consumed the T+T.

The above examples are particularly poor examples of recording, sadly they are all too commonplace. So, what would constitute “effective recording”?

Contemporaneous recording

It is a requirement to make records contemporaneously, this means as part of the care and support provided. In home care this will be at the end of the care visit if the visit is of short duration i.e. 30 mins, or at regular intervals if the visit is longer than 30 mins. In a care home or supported living setting this will mean after each care activity has been completed.  Records made many hours after the event will be of questionable quality, will not be consistent with the law, and will attract criticism from the CQC.

Link records to care plans and risk assessments

Records must provide clear evidence that the care plan was followed and how it was followed. They should also identify any deviations from the care plan and why this was. They should identify any possible changes required to care plans and risk assessments and how these were responded to. They should show how risks were managed and any changes in risk. E.g. If a service user was prescribed a new medication for hypertension the care plan should reflect this, the falls risk assessment should be reviewed and any additional control measures reflected in the care plan, records made by care workers should then evidence that the revised care plan and risk assessment have been followed in practice. The figure below illustrates the difference between integrated care plans, risk assessments, and records and the disparate system which is prevalent in poorly performing services.

DNA

Do Not Abbreviate - To the general public the abbreviation BO means “body odour”, to the care sector the abbreviation means “bowels open”. There is a world of difference between these bodily functions!!!!!   And, this is a so-called standard abbreviation, often care workers invent abbreviations such as; W&D, PCG, B/F, CPF (see bottom of the page for translation). The use of abbreviations saves no time at all, increases the risk of confusion by care workers, and is not consistent with the Accessible Information Standard and the requirement to communicate with people in their preferred format.

Fact not fiction

Records should record facts, if opinions are recorded then the record must make it clear that it is the opinion of the care worker. How can a care worker record “all well on leaving” if they do not back this up with some evidence of why all was well?  

Punctuation and grammar

Records made without punctuation risk unconnected events becoming commented. E.G “X is in a bad mood today her daughter visited” implies that X is in a bad mood because her daughter visited. Also, “in a bad mood” is the opinion of the care worker and this has not been backed up with any supporting evidence. If the record was made as “X was not very chatty today, she said that she felt a bit down. X’s daughter visited today ” then her mood is clarified with some evidence and her daughter is not being accused of being the cause of the bad mood.

Records are the only proof of the great job you do

If we go back to the opening statement “if it is not recorded then it didn’t happen” then it is clear that good records provide the only evidence that you do a great job of; meeting needs, managing risk, promoting independence, identifying changes in need or risk, involving the person, showing knowledge, skills, and competence. An ineffective recording is a missed opportunity to evidence compliance and good outcomes for people.

W&D – washed and dressed

PCG – personal care given

B/F – breakfast

CPF- care plan followed

T&T – tea and toast