Record-Keeping Principles

Best practice in record keeping is based on the key principles of partnership, openness and accuracy.

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/patients
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
Support for people and carers receiving services with specific communication needs so that they may contribute to and access their records and key information

Information should be recorded in accordance with the following key principles:

All relevant information must be recorded
Manual records must be legible, signed and dated
Records must be contemporaneous and kept up to date
Records must be written in plain English and prejudice must be avoided
Records must be accurate and adequate
Records must clearly distinguish between statements of fact and opinion
Managers must oversee, monitor and review all records
Records should be kept securely
Manual records moved to a new location must be monitored
Professional analysis, thinking, rationale for all decisions
Show management involvement, sign off all key decision points
Show referral by line manager to senior management/press office as needed

When and how should information be recorded?

When should information be recorded?

Records must be kept from the time that a concern, allegation or disclosure is made
Each entry must be dated and timed

The name of the person recording the information must be written in full. Do not use initials.

How should information be recorded?

All records must be legible and, if written, should be in black ink
Any alterations to records must be made by drawing a single line through a word(s)
Correction fluid must not be used
All records concerned with safeguarding children are strictly confidential

Health professionals must record all information in line with the record-keeping guidance of their own professional body.

Staff should be given clear direction as to what information should be recorded and in what format. The following questions are a guide:

What to record (1 of 3)

What information do staff need to know in order to provide a high-quality response to the child/young person concerned?
What information do staff need to know in order to keep a child/young person safe under the service’s duty to protect people from harm?
What information is not necessary?
What is the basis for any decision to share (or not) information with a third party?
All entries must provide factual information, e.g. times, dates, names of people contacted

Avoid expressions of opinion (remember that the person you are writing about may have the right to read what you have said).

What to record (2 of 3)

There should be a clear link between evidence recorded and actions planned/recommended
All contact with the child/young person and alleged perpetrator must be recorded
Record the exact words the child/young person and alleged perpetrator used
All consultation with a manager and/or senior manager must be recorded
When contacting other agencies the questions asked and information received must be recorded
If a decision is made not to contact the police, the details of why this decision was made and on whose authority it was made must be recorded

All telephone calls, those received and made in relation to the abuse, must be recorded even if there was no reply to outgoing calls.

What to record (3 of 3)

Those who attend strategy meetings must be named
The decisions taken at all meetings must be recorded
It is essential to demonstrate how an assessment of risk, responsibility, rights, autonomy and protection of the child/young person was undertaken
If no investigation is to take place, the reasons why and on whose authority this decision was taken must be recorded
All entries to be completed with the name of each person making an entry printed, signed and dated
A professional analysis of evidence, recommendations and rationale for these
Use body maps to illustrate physical injuries
When contacting other agencies the questions asked and information received must be recorded

Sharing Information

How do you share relevant information with other teams?

Information sharing

The Children Act 2004 places upon healthcare staff both an obligation to share information and an obligation to co-operate to safeguard and promote the welfare of children. If healthcare professionals have concerns about sharing information with others, they should obtain advice from named or designated professionals for safeguarding children. This should be undertaken as soon as possible to ensure little delay to the safety of the child or young person.

If concerns are based on information given by a child, healthcare professionals should explain to the child why they are unable to maintain confidentiality on this occasion, explore the child's concerns about sharing this information; and reassure the child that they will continue to be kept informed about what is happening.

When gathering collateral information from other health disciplines and agencies, professionals need to use their judgement about whether to explain to the family the need to gather this information for the overall assessment of the child.

Sharing dilemmas

All healthcare professionals sometimes have difficulty deciding whether or not to divulge what is, in most situations, confidential medical information. For example, a GP may find themselves having to support both the parent and child through the child protection process, and this may be a barrier to sharing information about child maltreatment concerns.

In this situation, it is recommended that each of the two parties should be cared for by a different GP in the practice; to enable both to act as advocate for their patient while working together in the best interests of the child.

There are constant tensions between the way general practice works (a confidential service based on a relationship of trust) and the need to share information in order to protect children from abuse and neglect.

The law is clear that where concerns are evident, then it is necessary to share concerns and key elements of information to aid the Local Authority in undertaking their investigation and supporting the child effectively. This will include the necessity of sharing information about the parent or guardian.

Your professional obligation

In the event of a child protection concern, the expectation is that GPs and other healthcare professionals should disclose information, though consent should usually be sought first, provided this does not endanger the child.

The GMC would seek justification from a GP or doctor who did not disclose. The GMC's 0-18 years guidance advises that 'you will be able to justify raising a concern, even if it turns out to be groundless, if you have done so honestly, promptly, on the basis of reasonable belief and through the appropriate channels’.

The central conundrum is that it is often not possible to determine whether or not there is a child protection risk until after the information has been shared between agencies. However, in order to maintain a confidential service, the threshold of concern for professionals that triggers such a sharing should remain high. This is a complex area and healthcare professionals are advised to seek advice from their defence organisation in difficult situations.

Early intervention

The aim of the Common Assessment Framework (CAF) (and similar multi-disciplinary frameworks in other jurisdictions) is to identify at the earliest opportunity a child's or young person's additional needs which are not being met by the universal services they are receiving. CAF is intended to provide timely and coordinated support to meet those needs.

CAF can be an important tool for early interventions in safeguarding. It is designed for use when:

You are concerned about how well a child is progressing. You might be concerned about their health, welfare, behaviour, progress in learning or any other aspect of their well-being
The child, their parent or another person may have raised a concern with you
The needs are unclear, or broader than your service can address
A common assessment would help identify the needs of a child, and/or get other services to help meet them

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