Writing effective care records

The legal requirements

Regulation 17(2)(c) of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 states that the registered person(s) must maintain securely an accurate, complete, and contemporaneous record in respect of each service user, including a record of the care and treatment provided to the service user and of decisions taken in relation to the care and treatment provided.

Regulation 17(2)(d) states that the registered person(s) must maintain securely such other records as are necessary to be kept in relation to the persons employed in the carrying on of the regulated activity, and the management of the regulated activity

From this, it is clear that care providers must securely maintain accurate, complete, and detailed records in respect of each person using the service and records relating to the employment of staff and the overall management of the regulated activity.?These records must be fit for purpose. The CQC defines this as.

• Being complete, legible, indelible, accurate, and up to date, with no undue delays in adding and filing information, as far as is reasonable. This includes results of diagnostic tests, correspondence, and changes to care plans following medical advice.
• Including an accurate record of all decisions taken in relation to care and treatment and referring to discussions with people who use the service, their carers, and those lawfully acting on their behalf. This includes consent records and advance decisions to refuse treatment. Consent records include when consent changes, why the person changed consent, and alternatives offered.
• Being accessible to authorised people as necessary in order to deliver people's care and treatment in a way that meets their needs and keeps them safe. This applies both internally and externally to other organisations.
• Being created, amended, stored, and destroyed in line with current legislation and nationally recognised guidance.
• Being always kept secure and only accessed, amended, or securely destroyed by authorised people.

Ineffective care records

?As can be seen from the CQC guidance on this aspect of Regulation 17 care records must be complete, accurate, and made at the time that the care and support are provided (contemporaneous). An examination of CQC inspection reports for services rated as inadequate or requiring improvement shows many areas of criticism which include incomplete records, records that could not be found, inconsistent records, failures of record storage and archiving, incorrect records, false records, and records not being accessible to staff.?In this article, we will focus on one aspect of record keeping and that is making effective records of care and support provided. With the move to digital care records, there is an increasing tendency for care records to be created automatically by staff ticking a check box on a handheld device. This is all well and good if it relates to a critical care activity that must be completed at a set time. But this is not an effective way to make records of the care and support provided and the outcome for the person. Nor is this task-focused recording effective at identifying changes in need or risk. Sometimes when auditing such care records, I feel that I know in great detail about a person’s bowel movements and what they had for breakfast, albeit often recorded as happening at 11.21am!! But I can glean nothing about the involvement of the person in their care or what sort of day they had. Of course, digital systems provide the opportunity for such narrative records to be made but given the time pressures on staff who work in care services it is easy to understand why such narrative records are lacking in quantity and quality on many occasions. Handwritten records face different but equally worrying issues, often such records are merely a record of what the staff member has done with no detail on the outcome of this. Sometimes the records are bland and monotonous such as the classic home care record of yesteryear. “Care plan followed, all well on leaving”.?I have seen many examples of handwritten care records being made many hours after the activity was undertaken and as we all know our powers of recollection fade with every passing minute.

Effective care records

Irrespective of whether care records are made in handwritten or digital format they still need to meet the following criteria.

• Provide evidence of the care and support provided - this must link to the person's care plan and must show how the care and support have been provided. If the care plan and the records are compared it should be easy to identify the links between them.?
• Show the input of the person – the care records must show that the person was included in their care, a participant rather than a passenger so to speak. This requires the person making the records to think about how they construct the record so that it shows who did what.
• Demonstrate choice, voice, and control – this is essential, and the records should show how people are supported to have genuine choices about how their care is provided, supported to have a voice, and above all have control over how the care is provided to meet their outcomes that day.
• Provide evidence of how care contributes to meeting outcomes – outcomes are the intended result of the care intervention, records must not only link to outcomes but must show how every action has worked towards meeting outcomes.
• Identify changes in need – people’s needs change, hopefully for the better but often they become more significant. Records must show how needs are monitored and responded to.
• Provide evidence of proactive care- care and support must focus on a proactive rather than a reactive approach. This means anticipating future needs and issues and evidencing that these are monitored and responded to before they become problems.
• Show continuity of care – it should be clear from care records that social care workers have read and responded to the records made by the worker who provided the previous care intervention, it should also be clear when workers have provided information for workers who will be providing the next care intervention. ?
• Written at the time – this is essential, not only is it a legal requirement but the quality of the record diminishes significantly with time.

Support staff to make effective records

Care providers must establish systems and processes that enable and support staff to make records that are effective, and contribute towards meeting people’s outcomes. This requires thought about the system, training for staff in how to use the system and make good records, auditing of records, and a focus on continuous improvement.?In all the examples from poor inspection reports cited earlier, the Registered Manager was unaware that the issues with records existed until the CQC pointed them out that is!?The records that we make are the only proof of the care that we provided today, and systems should be designed with a focus on providing evidence of this.