This page is designed to answer the following questions:
- 14.1c Demonstrate how to keep records that are up to date, complete, accurate and legible (Care Certificate, Standard 14: Handling information)
- 3.1 Keep records that are up to date, complete, accurate and legible (Level 2 Diploma in Care, Handle information in care settings)
- 2.3 Maintain records that are up-to-date, complete, accurate and legible (Level 3 Diploma in Adult Care, Promote effective handling of information in care settings)
- 2.3 Maintain accurate, complete, retrievable and up to date records (Level 4 Diploma in Adult Care, Develop, Maintain and Use Records and Reports)
NOTE: This page has been quality assured for 2021 as per our Quality Assurance policy.
All records that you keep and documentation that you are responsible for must adhere to certain standards to ensure that they are lawful, fit for purpose and adhere to your duty of care and other responsibilities. In short, this means that any records you complete should be up to date, complete, accurate and legible.
Up to date records
Records should always be up-to-date. Documentation such as care plans are constantly changing and should be regularly reviewed to ensure that they fulfil the individual’s current needs, wishes and preferences. Old documents could result in a member of staff performing tasks that are no longer required and possibly even harmful to an individual (e.g. administering medication that is no longer needed). Any changes to records should also be signed and dated and an audit trail maintained so that the history of the document is kept on record. Important information such as the address and contact number of the individual’s next of kin or GP can change regularly, so it is important to ensure these are kept up-to-date.
All records should be fully completed to ensure that no information is missed. You should aim to include as much detail as possible and include the time, date and your signature. Incomplete records could result in staff not being aware of the whole picture or having to use guesswork. Setting a regular time and routine for completing documentation can help to ensure things are not missed.
It is essential that all records are 100% accurate. This means sticking to the facts and writing in an objective manner. You should not include your personal feelings or opinions. If records are not accurate, it could result in incorrect conclusions being drawn and an individual receiving the wrong care and support. Ensuring that you record information as soon as possible helps with accuracy because the information will still be fresh in your mind.
All records must be legible so that anyone reading them can understand and comprehend them. This may mean slowing down your writing or writing in block capitals to ensure clarity. If others cannot read the records you write then they will not be of any use. Any errors should be clearly deleted with a single line striking through the unwanted words – ink-remover or correction fluid should never be used.
Example question and answer
Prepare a set of guidelines to remind social care workers of best practice in handling information.
In the guidelines, you must:
- Explain how to maintain records so that they are up to date, complete, accurate and legible.
- Describe how to ensure records are stored securely.
- Describe how to ensure security when reading or making entries into records.
- Describe any special feature of different storage systems that help to ensure security.
BEST PRACTICE FOR HANDLING INFORMATION – Guidelines for Adult Care Workers
These guidelines are written for adult care workers and aim to explain best practices for handling information including record maintenance, storage and security.
All records should be written neatly and legibly in black ink and should be clear, concise, factual and accurate. Any errors should be clearly marked by putting a line through it and initialling and all forms should be completed Pro-forma. This will ensure that all records are comprehensible to anyone reading them and all the necessary details are included. Records should be completed as soon as is practicably possible so that it is fresh in your memory and should be kept up-to-date. They should be completed in private with no risk of being observed by unauthorised individuals. The time, date, your signature and printed name should be included on all records to ensure transparency and accountability.
Records should be stored in accordance with legislation, company policies and best practices. This means ensuring they are stored in a safe place that cannot be accessed by anyone unauthorised. This may mean in a locked room or a locked drawer. Records should not be removed from the workplace unless absolutely necessary and returned to secure storage as soon as they’ve been updated. Electronic records should be stored securely as well with password protection and permissions so that only authorised personnel can access them. Records should be kept only for as long as needed and then disposed of properly (e.g. shredded).
Ensure Security When Reading/Updating Records
As mentioned previously, records should only be read or updated in a secure and private location that is free from prying eyes. You should also ensure that nobody can overhear you when talking about personal information. Once you have finished reading or updating, the records should be returned to their secure storage immediately. Electronic documents should not be left open on a computer if you have to leave. You should either close them once you have finished or lock your computer if you move away from it.
Special Features of Storage Systems
Paper records are usually stored securely in cabinets or drawers that are protected by a lock and key. They will also be stored in a locked room. Only authorised people will have access to them because only they will have the key. Electronic records should always be password protected and stored on secure computer systems. Only people that have the password or have been given authorisation on their user account will be able to access them.