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Record Keeping - Recording Guidance


Contents

  1. Introduction
  2. Record Keeping Principles
  3. The Context
  4. Record Keeping by All Agencies
  5. What to Record
  6. When Should Information be Recorded?
  7. How to Record Information
  8. Storing and Filing Information
  9. Child Alleged to Have Caused Harm

    Further Information


    Amendments to this Chapter


1. Introduction

All organisations should refer to their own professional/agency guidance on record keeping.

Whenever a complaint or allegation of abuse is made, all agencies should keep clear and accurate records. Each agency should have procedures for incorporating all relevant agency and subject records into a file to record all actions taken.

Any Agency files may need to be made available to the courts.

Records belonging to providers including providers of regulated services should be available to the commissioners of services and to the Public Health Department, Professional Care and Regulation Team. All records must be stored in accordance with your own agency’s policies with regard to the Data Protection (Jersey) Law 2005.

Access to files may also be requested by service users.

All agencies should identify arrangements, consistent with principles of fairness, for making records available to the subject and those with parental responsibility.


2. Record Keeping Principles

Best practice in recording is based on key principles of partnership openness and accuracy

Good quality case recording is essential in ensuring:

  • Continuity of service to children and families when staff are unavailable or change, or when a service resumes after a period of time;
  • Effective risk management practices to safeguard and promote the welfare of children and young people, especially in emergency situations;
  • Clarity of the assessment process and decision-making Effective partnerships between staff, children, young people, their families and Carers, and other agencies/services;
  • Clarity of information for everyone involved in the planning and delivery of services, and in the event of child protection investigations, inquiries, or audits;
  • Adequate information for staff and managers working to ensure the best possible outcomes for children and young people;
  • Support for children, young people and families with specific communication needs so that they may contribute to and access their records and key information.

Information should be recorded in accordance with the following key principles:

  • All relevant information must be recorded;
  • Manual records must be legible, signed and dated;
  • Records must be contemporaneous and kept up to date;
  • Records must be written in plain language and prejudice must be avoided;
  • Records must be accurate and adequate;
  • Records must clearly distinguish between statements of fact and opinion;
  • Managers must oversee, monitor and review all records;
  • Records should be kept securely;
  • Manual records moved to a new location must be monitored;
  • Show professional analysis, thinking, rationale for all decisions;
  • Show management involvement, sign off of all key decision points;
  • Show referral by line manager to senior management as needed.


3. The Context

Good record keeping is essential so that agencies are able to demonstrate that decisions were taken lawfully. Documentation in relation to a Safeguarding process can be significant in providing supporting evidence when making referrals to the Disclosure and Barring Service Barred List, care proceedings, criminal cases, the Royal Court, disciplinary hearings and complaints. Record keeping is an integral part of professional practice and should support decision making. Decisions and action taken should be supported by evidence and rationale so that intentions are clear.


4. Record Keeping by All Agencies

Each agency must keep comprehensive records of any work which it undertakes particularly in response to child protection processes and looked after children processes.


5. What to Record

  • All entries must provide factual information, e.g. times, dates, names of people contacted;
  • Distinguish what is fact, professional opinion or hypothesis. Provide reasons for opinion or hypothesis. There should be a clear link between evidence recorded and actions planned/recommended;
  • All contact with the child, young person and family members/significant others and the person alleged to have caused harm used;
  • All consultations/case supervision with and decisions made by a Manager and/or Senior Manager must be appropriately recorded;
  • When contacting other agencies the questions asked and information received must be recorded;
  • Where, upon reflection, a decision is made not to contact the Police, or make an enquiry to MASH, the details of why and how this decision was made must be recorded;
  • All telephone calls/texts and emails, in relation to the alleged abuse, must be documented even if there was no reply to outgoing calls;
  • If reference is made to another person involved with the child or family, that person’s name as well as their agency status should be recorded;
  • The decisions taken at all meetings must be recorded;
  • There should be an ability to print, sign and date all records;
  • Use Body Maps (see Body Maps-Male and Female with Guidance Notes) to illustrate physical injuries.


6. When Should Information be Recorded?

  • Records must be kept from the time that a concern, allegation or disclosure is made;
  • Each entry must be dated and timed;
  • The name of the person recording the information must be written in full. Do not use initials.


7. How to Record Information

  • All records should be typed and stored electronically. However contemporaneous notes, written at time of disclosure, should be kept in accordance with agency procedures;
  • Any alterations to records must be made by drawing a single line through a word(s) and signed;
  • Correction fluid must not be used;
  • All records concerned with Safeguarding/child protection are confidential.


8. Storing and Filing Information

  • All records or files must be stored in accordance with each agency's own policies and with regard to the Data Protection (Jersey) Law 2005.
  • It may be inappropriate to document/store certain child protection information in the place normally used for service user records if, for example, the person alleged to have caused harm or associates may have access to that record. Advice should be sought from the Agency’s Safeguarding Lead in this instance and agency procedures for the storing of confidential information followed. Advice should be sought from that Agency’s Safeguarding Lead or their line manager if the Safeguarding Lead is conflicted;
  • Each agency should ensure there is a protocol in place detailing the length of time for which records are to be held in line with requirements.


9. Child Alleged to Have Caused Harm

  • If the person alleged to have caused harm is a child/young person then information about his/her involvement in a child protection investigation, should be included on his/her case records as they are likely to be considered a Child In Need or In Need Of Protection.


Further Information

Data Protection (Jersey) Law 2005

Freedom of Information (Jersey) Law 2011

Amendments to this Chapter

In March 2017, this chapter was updated including Section 7, How to Record Information, all records should be typed and stored electronically. However contemporaneous notes, written at time of disclosure, should be kept in accordance with agency procedures.

End.