Drink and Drugs News DDN July_August 2019 | Page 18

LegaL Line
More legal advice at:
www.drinkanddrugsnews.com
Accuracy and detail are key for
providers, says Jenny Wilde
For the record
It is difficult to overstate how important good
record-keeping is within health and social care
settings. Good record-keeping ensures that
relevant information is captured for use by carers
and other professionals. That information may be
needed for a variety of reasons including:
• identifying trends for use in risk assessments
• monitoring changes in medical conditions
• providing evidence that appropriate care is
being delivered
All too often we see care records that use
shorthands such as ‘all care given’. A rule of
thumb that carers may find useful is ‘if it isn’t
‘In a nutshell,
when it comes to
record-keeping, be
thorough and seek
help if you need it.’
recorded, it didn’t happen’. All care, all responses
to particular incidents, all discussions with
professionals and other stakeholders – anything
18 | drinkanddrugsnews | July/August 2019
at all that is done or said about a service user –
MUST be recorded.
Poor record keeping generates serious risks.
First, and most importantly, service users are
potentially at serious risk if important information
is not captured and communicated effectively.
That can lead to anything from failing to identify
service users’ lifestyle preferences to mistreating
medical conditions in a life-threatening way.
There is, however, also a serious risk to carers
and other professionals of poor record-keeping. In
any investigation into the treatment of a service
user – for example a safeguarding investigation or
a compliance review by the Care Quality
Commission – the care plan is the first document
that will be looked at. Applying the rule of thumb
identified above, investigators will be very slow to
accept that appropriate action was taken if it was
not contemporaneously recorded. Those with
professional registrations, such as nurses, also risk
disciplinary action if they fail to meet professional
standards about record-keeping.
Writing reports requires even more care as
they are bound to be scrutinised carefully. Senior
management or legal advice should be sought in
appropriate cases.
In a nutshell, when it comes to record-keeping
be thorough and seek help if you need it. The CQC
will rely heavily on records during inspections and
will not hesitate to criticise a service that shows
flaws in its record-keeping processes.
Jenny Wilde is director at Ridouts solicitors
WHAT, THEN, ARE THE KEYS TO
GOOD RECORD-KEEPING?
The following are some useful tips:
• ASSUME that the person reading your notes
has no previous knowledge about you or the
service user in question. The more detail the
better. If you find yourself too busy to make
full notes, the service is understaffed. Raise
the issue with your manager and if that
doesn’t resolve matters, consider using the
whistleblowing procedure.
• KEEP a record of your efforts. Ensure that you
don’t take the fall for a service being under-
resourced.
• SEEK and exploit training opportunities.
Record-keeping is a skill which is learned and
professional training can be a great help.
• SEEK support from managers and colleagues if
necessary. This is especially important for new
entrants to the care sector, those who do not
speak English as a first language and anyone
with dyslexia or literacy difficulties.
www.drinkanddrugsnews.com