Recording is an integral and important part of our roles. It is not simply an administrative burden to go through as quickly as possible, but is central to good practice.

Recording is vital because:

• It supports good care and support.
• It is a legal requirement and part of staff’s professional duty.
• It promotes continuity of care and communication with other agencies.
• It is a tool to help identify themes and challenges in a person’s life.
• It is key to accountability – to people who use services, to managers, to inspections and audits.
• It is evidence – for court, complaints and investigation.

Good recording will enhance your practice and the support you can offer people if you can make it a central part of your work.

It is vital to get recording right.  We usually know what to do but this is often difficult, given the many pressures on your time and other challenges of your job. 

The following resource shows 11 top-tips for good recording and uses the acronym 'PARTNERSHIP' as a checklist, and to emphasise that the record should be co-produced between you and the person to whom it relates.  You can view the resource here. 

• Person-centered
• Accurate
• Real
• Timely
• No Jargon - Plain English
• Evidence-based
• Reading the previous record
• Succinct
• Holistic
• IT Compliant
• Professional

When recording information, ask yourself the following questions:

• How would it feel to the individual or their family/carer to see the language that is being used to describe them/their lives?
• What does the use of this language imply about the individual?
• How will others interpret this information if I am not there to explain the context?

The wrong language can silence people by making them feel shame or blamed and can negatively influence the quality of interventions offered to someone as it can normalise, minimise, and dehumanise the person's experience, resulting in a lack of appropriate response.  Professionals reading the persons records may form a prejudiced opinion about the person based on what is recorded and this may lead to unconscious bias and malignant alienation.

The Social Care Institute for Excellence (SCIE) have produced 3 short films which illustrate the negative impact poor recording can have.  They demonstrate that recording is part of making sure people's wellbeing is promoted, not just an add-on to your work.  

Click on the links below to watch the short videos:

• The perspective of the Person who uses services
• The perspective of the Professional
• The perspective of the Carer

• Digital Records: Use strong passwords and encryption.  Access should be restricted to authorised personnel only.
• Physical Records: Store documents in locked, secure cabinets.  Access should be controlled and limited to authorised staff.

Working closely in people’s lives means you’re going to find out deeply personal information about them. As a person in a position of trust, you must keep this information confidential.

However there will be times that as a professional you may need to share information.  Take a look at CSAB's Information Sharing Guidance by clicking here.