This guidance sets out our standards for record-keeping, ensuring our records are always of a high quality, clear, easy to read, and written with kindness. It covers both our written and electronic records for each person open to services. Our records should:
- Help us understand the person's life and our involvement in it,
- Explain the reasons behind our professional decisions,
- Show that we're meeting our legal requirements,
- Be written in a way that puts the person at the centre,
All services across the system should be made aware of this guidance during their induction, and it should be referred to during supervision and training. Good record-keeping helps us explain what we did and why in a way that makes sense. It doesn't need to be time-consuming. It should be clear and accurate; records help us capture important information that is meaningful.
The guidance can be used across the system, inclusive of partners and providers to provide to promote good care recording and the use of appropriate language.
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