Produce accurate and coherent records and reports that can be understood by those who have a right to see them

For this assessment criterion, you will be required to produce accurate and coherent reports that can be understood by those who have the right to see them.

As touched upon in the previous section, records and reports should be delivered in a format that is accessible to all individuals that are authorised to access them. For example, an individual with a learning disability may require information to be provided in an ‘easy-read‘ format so that they are able to understand the content. Similarly, if the information is for the use of trained health professionals, it may contain scientific terms or field-specific jargon, however, this would not be suitable for the individual or their family.

There should be careful consideration about how the information may be perceived by the recipient when communicating via text or email – it can be difficult to express tone in these media and you should not assume that everyone understands ‘textspeak’ (for example, an individual I worked with thought that ‘lol’ meant ‘lots of love’ rather than ‘laugh out loud’!)

Of course, all legal and regulatory requirements pertaining to the recording, storage and sharing of information should be adhered to and access should be restricted to only those that ‘need to know’. Confidentiality should be respected at all times and consent should be obtained from the individual before sharing their personal information with others. Systems and agreements should be in place for sharing information externally.

All records should be up-to-date, accurate, complete and legible and based on facts and evidence. Personal views should not be recorded (unless a professional opinion has been requested).