This page is designed to answer the following questions:
- 3.3 Demonstrate the use of facts and evidence-based opinions within records and reports (Level 4 Diploma in Adult Care, Develop, Maintain and Use Records and Reports)
- 3.4 Evaluate how own records and reports provide evidence for the basis of judgements and decisions (Level 4 Diploma in Adult Care, Develop, Maintain and Use Records and Reports)
NOTE: Although this page has been marked as complete, it has not yet been peer-reviewed or quality-assured, therefore it should be considered a ‘first draft‘ and any information should be fact-checked independently.
For this assessment criterion, you will be required to demonstrate that you use facts and opinions that are evidence-based within reports and records.
We have already spoken about the need for records to be accurate and factual. This means that records should be objective and not contain your own personal views and opinions. The only exception might be if you are asked to make a professional judgement based on your experience.
You should also ensure that the source of any information you provide is reliable – for example, the opinion of an individual’s family member should be clearly labelled as an opinion, rather than a fact, unless there is evidence to back it up.
The facts and evidence that are presented in records and reports may be used by yourself or others to form judgments or make decisions, so accuracy is essential to ensure that the right decision is made. For example, if an individual that you support begins to wet themselves regularly, you should maintain records of when this occurs as well as the fluids that they drink. This may assist the doctor in forming a professional judgment about what is happening. When in doubt, you should clarify the accuracy of information with others.
To be accountable for the actions we take and the decisions we make, we must ensure that the things we do as part of our professional practice are based on facts and evidence. This should be reflected in any and all reports and records that we write.
For example, you may recommend that an individual with a learning disability is prompted to go to bed by care staff at 10pm (whilst still giving them the choice) as part of their care plan. The purpose of this judgment could be related to positive behaviour management having identified that the individual becomes aggressive towards staff on the day following a late night. As well as helping you to identify a potential cause of the issue, good record-keeping also supports your recommendation.