Top tips for social care providers on good record keeping

Dementia Care
March 8, 2023

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Last month, the Local Government and Social Care Ombudsman released a good practice guide for care providers relating to good record keeping.

Why have they done this? Well, the Ombudsman believes that social care providers are not always good at keeping their records and the guide stresses the importance of doing so. At QCS, we can offer some tips and techniques that will show you how to achieve good record keeping.

The themes raised in the guide state that the areas where providers appear to struggle are:

  • Not keeping comprehensive records
  • Not ensuring records are accurate
  • Not retaining relevant information for action

These points can have serious impact and consequences for service users. It is likely that the Ombudsman and CQC will find the care provider at fault when dealing with illegible or inaccurate record keeping.

How to achieve good record keeping

So, what can you do as a provider to ensure that your records are informative, accurate and relevant?

  • Decide upon a method of record keeping and stick to it. Ensure that this method of recording information runs concisely and coherently throughout your organisation, and that all staff are fully aware of the method, how to implement it and the importance of why it must be done
  • Ensure that your system records distinct aspects of care delivery and service user monitoring. To include, but not limited to, medication charts, body maps, financial transaction records and records of care
  • Medication should be individually listed with clear instructions as to the set times of day or PRN, dose and a description of the tablet/capsule/liquid. The medication should be individually recorded on the electronic/paper MAR
  • Through training, staff should be fully aware of the potential consequences of failing to record entry and exit times correctly. If staff are falsifying records this leaves them completely open to accusations about theft, medical assistance or even death
  • Review and audit your records on a regular basis, at least monthly as a minimum
  • Share incidents and stories relating to investigations you are aware of that have occurred through poor record keeping – several are listed in the Ombudsman’s Good Practice Guide
  • Don’t attempt to cover anything up. If an incident has occurred, covering up an error rather than being candid is unlikely to work in your favour in an investigation, and will result in mistrust in your record keeping as an organisation as a whole

Written Records

If you are using written records instill the following:

  • Make sure that your staff are issued black pens – it is important that documents are written in black ink so that they can be photocopied as and when necessary
  • Staff need to understand the importance of writing legibly and use the pages sequentially, it is imperative that anyone can read their writing and understand the order of events

Electronic record keeping

If you are using electronic records instill the following:

  • Through your training, staff should understand the importance of including a typed manual entry, so that the care provision does not become merely a task based tick box exercise. Staff should understand that writing a short record demonstrating choice, consent, actions and inactions, is imperative to evidencing bespoke, person-centred care delivery
  • Consider photographing food that is served and uploading to the service user’s daily record, this demonstrates that the service user has been provided with variety and choice in their diet

Ultimately, this all boils down to effective and thorough training and monitoring. If you are consistent and open in your approach as a provider, this will filter down to your staff and ensure that they keep accurate and detailed records.

Further Information

Download the Good Practice Guide – Good Record Keeping from the Local Government and Social Care Ombudsman.

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