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Record Keeping

SCOPE OF THIS CHAPTER

This guidance outlines the importance of good record keeping when working with children and families. It also sets out the specific recording requirements which should be followed when a request to share information is made.


Contents

  1. General Principles
  2. Record Keeping in Relation to Information Sharing
  3. Record Keeping in Relation to “Case by Case” Information Sharing

    Further Information


1. General Principles

Good record keeping is an essential part of the accountability of professionals to those who use their services. It helps focus work and it is essential to working effectively across agency and professional boundaries. Clear and accurate records ensure that there is a documented account of an agency's or professional's involvement with a child and/or family. They help with continuity when individual workers are unavailable or change, and they provide an essential tool for managers to monitor work or for peer review.

Records are a source of evidence for investigations and enquiries, and may be required to be disclosed in Court Proceedings. Where Section 47 Enquiries do not result in the substantiation of referral concerns, records should be retained in accordance with agency retention policies. These policies should incorporate the safe storage of information and retrieval of records.

To serve these purposes records should use clear, straightforward language, be concise, and be accurate not only in fact, but also in differentiating between opinion, judgement and hypothesis.

Safeguarding and promoting the welfare of children requires information to be brought together from a number of sources and professional judgements to be made on the basis of this information.

Where decisions have been taken jointly across agencies, or endorsed by a manager, this should be made clear.

All agencies need to be aware that all records (notes, minutes, plans etc) can be potentially disclosed as evidence in criminal and civil proceedings.

Children and families must be informed that records are being kept and that they have a right to access these.


2. Record Keeping in Relation to Information Sharing

Recording information sharing decisions, including the reasons for the decisions, is necessary as part of the audit trail. These records can help other practitioners understand what happened and why and help to avoid duplication. Without these records it may be difficult to prove that due process was followed if legal action is brought against an organisation (see 'Information Sharing: How to Record Decisions').


3. Record Keeping in Relation to “Case by Case” Information Sharing

3.1

Where you decide it is appropriate to share personal information with another agency or service you must ensure that you record:

  • Your reason for sharing the information;
  • Whether you are sharing with or without Consent;
  • If sharing without consent, why;
  • Who consented to the information sharing, if appropriate;
  • Any limits to the consent to share all or some of this information with others;
  • Whether the person or family concerned were informed of the sharing and, if not, why not;
  • What type of information you shared;
  • How you shared the information, e.g. email/phone/in writing;
  • The recipient’s name, job title, organisation and telephone number;
  • The outcome of the sharing and the next course of action;
  • How was the receipt of the information confirmed; and
  • The date and time of the contact, and the name and signature of the person making the entry.
3.2

Where you have received a request to share information with another agency or service you must ensure that you record:

  • The requester’s name, job title, organisation and telephone number;
  • How the identity of the requester was confirmed (e.g. ring back);
  • The reason for the request and a summary of the information requested with a case reference, if available;
  • Consent issues, as in Section 3.1 above;
  • Whether the person or family were informed of the sharing and, if not, why not;
  • Any limits to the consent to request all or some of this information with others;
  • Your decision (whether or not to share) and the reason/s for this decision;
  • What type of information you shared;
  • How you shared the information, e.g. email/phone/in writing;
  • Any outcome or course of action as a result of the sharing;
  • The date and time of the contact, and the name and signature of the person making the entry.
3.3

If you request personal information from another agency or service you must ensure that you record:

  • Date and time;
  • The Practitioner’s name, job title, organisation and telephone number;
  • How your identity was confirmed (e.g. ring back);
  • The reason for the request and a brief summary of the information requested, with a case reference, if available;
  • Whether you are requesting the information with or without consent;
  • If requesting the information without consent, why;
  • Who consented to the request for information, if appropriate;
  • Any limits to the request for all or some of this information from others;
  • What information was shared;
  • How the information was shared, e.g. email/phone/in writing;
  • If the decision is not to share, the reasons and any actions taken as a result of this decision;
  • Any outcome or course of action as a result of the sharing; and
  • The name and signature of the person making the entry.

Further Information

See also Information Sharing: How to Record Decisions (DfE).

End.