How to Complete Records
At Active Records should be Completed in Accordance with the Following:
- An entry should be made at the end of each shift, or as you go along as appropriate
- Records should be written legibly, in black ink
- Entries should be factual, consistent and accurate and not contain jargon, abbreviations or meaningless phrases (e.g. ‘ate well’, ‘no problems’, ‘all ok’ – need to detail what was eaten and quantity, say what did happen rather than what didn’t)
- Entries should include a date, time and duration of visit. Staff should ensure the times they work is in accordance with the times detailed on the Client Visit Schedule, or adjust it accordingly and inform the Rota Department.
- Each entry should be followed by a signature and printed name
- Confidentiality of other service users should be respected if referred to in another person’s daily notes i.e. use initials only.
- Correction fluid e.g. Tippex should not be used. Any corrections should be made by scoring through the error with date, time and initials of who has done this
- Ensure client and/or their representative is aware of what has been written on the record, and have access to it. Be considerate in respect of written comments made so as not to unduly or unintentionally offend or upset the client as they and their family/representatives are entitled to read it
- Check records demonstrate service is being delivered in accordance with the Person Centred Support Plan and that clients are working towards outcomes.
- Records need to be stored securely either at Head Office or in the clients home. Information about the records should only be shared with those who have a genuine reason for needing to know.
Use to answer question 14.1c of the Care Certificate