Case Recording

Good quality case recording is essential in ensuring:

• Risk and protective factors should be identified;
• Continuity of service to children and families 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 children, especially in emergency situations;
• Effective partnerships between staff, children, their families, their carers, other agencies and service 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 to ensure the best possible utilisation of available resources;
• As a means by which to ensure accountability and adherence to procedures and statutory responsibilities.

Records may be in the form of paper files and/or computer records; audio or video recordings may also be kept. Separate case/file records must be made for each child.

All case records must be organised in order to safeguard the 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 the 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.

Where information is held on a paper file, the electronic record must be used to identify the source and location of the paper record.

Forms must be completed in all fields as indicated by the agencies instructions and signed and dated.

Individuals have a right to be informed about their records, the reasons why they are kept, their rights to confidentiality and how to access their records.

Information should be provided in a form that individuals will understand. An interpreter should be provided if needed.

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

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 the record as well as stating their post title. There must be clear differentiation between opinion and fact.

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

Every case file or electronic record must be completed with information about the individuals full name, address, date of birth, ethnicity, religion, any reference or identification number, any risk assessment, a transfer/closing summary (where appropriate) and, in the case of paper files, volume number.

Children (depending on their age and understanding) and their families 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 in respect of services they may receive.

Generally, they must also be asked to give their agreement to the sharing of their information with others, except where there are concerns about Significant Harm. For further guidance about when information can be shared without consent being sought, see Information Sharing Procedure. Where there is uncertainty about information sharing where there are concerns about Significant Harm, staff should consult with supervisors / managers.

Those completing computerised records must show their name, post title and the time and date when the recording was completed. The sequence of the recording must also be noted.

Paper records should be typed or clearly handwritten and all records must be signed, dated and the persons post title stated.

Any handwritten records must be legible.

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.

Records should be completed contemporaneously or as soon as practicable after the event occurs and should be updated as information becomes available or as decisions or actions are taken.

Where records are made or updated late or after the event, the fact must be stated in the record, and the date and time of the entry should be included.

All agencies must adhere to their own agency recording policy and procedures.

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 way which is sensitive to differences of diverse ethnic and religious backgrounds and lifestyles.

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.

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.

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.

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 audit records to ensure they are up to date and maintained as required and, if not, that deficiencies are rectified as soon as practicable.

All management recommendations, decisions and actions must also be recorded and regularly reviewed.

All records must be kept securely, including electronic records; ideally these should be password protected and transfer of information across agencies.

Paper records will be kept in folders with all documents firmly affixed to prevent their loss.

Files in paper form should 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.

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. 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.

Care must be taken so that records on laptops, discs, memory sticks, CD's or other information storage devices are password protected and removed only in accordance with each agencies procedures.

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

Files should be retained for the period set out in each agencies own record retention policy.

In all agencies the relevant policies relating to retention and destruction apply and any member of staff responsible for a child’s records when services end and the case is closed, is responsible for ensuring that the records to be retained are in good order and that unnecessary items have been removed, for example, compliment slips, duplicate copies etc.