Case recording is an essential part of daily social work practice. It involves:
- writing down the work that has been undertaken;
- documenting the progress adults make towards their desired outcomes;
- recording the views of the adult and their carers;
- life history, assessment and analysis.
Case recording provides an evidence trail of the work done with an adult, and their carer.
Staff should always remember that in the event of a safeguarding inquiry or other investigation, case records will be used and scrutinised. Staff will be held accountable for all entries they make.
Staff should always consider this when documenting their actions and professional judgements. Staff should also remember that records may be shared with the adult, and this should influence the language used and the manner in which judgements are recorded. Case recording is also a vital tool to enable staff to reflect on their ongoing work with adults / carers and plan future work. They should be used as part of supervision, in conjunction with their supervisors / managers.
2. The Purpose of Case Recording
Whilst some of the main tenets of recording have been noted above, overall the purpose is to:
- document the involvement of adult social care services with the adult / carer, including the provision of services;
- inform assessment and care and support planning;
- enable staff to review and reflect on their work;
- assist staff in identifying any patterns;
- ensure accountability for actions taken and not taken, with reasons – documents decision making and thinking;
- meet statutory requirements;
- provide evidence for legal proceedings;
- assist with practice continuity, if new staff begin working with the adult;
- provide performance information;
- provide evidence for inquiries, review or complaints;
- assist partnership working between staff and adults / carers
- document risks and risk management / contingency plans (see Risk Assessments);
- document risk, autonomy, responsibility and safeguarding from abuse.
3. Principles of Case Recording
Case records should
- be based on a general principle of openness and accuracy:
- be drawn up in partnership with the adult;
- record the views of the adult, in their own words where appropriate, including whether they have given permission to share information;
- be an accurate and up to date record of work, which is regularly reviewed and summarised;
- include a record of decisions taken and reasons for them;
- include a chronology of significant events;
- be evidence based and ethical;
- separate fact from opinion;
- incorporate assessment, including risk assessment where appropriate;
- include an up to date care and support plan (see Care and Support Planning); and
- record race/ethnicity, gender, religion, language, disability
- training, journals and articles should be used to keep up to date with research developments to inform recording;
- be used by the supervisor / line manager as part of overall measurement of staff performance.
- In the case of hard copy records – be legible, signed and dated;
- include management sign off for major decisions and referral onto senior managers;
- be kept securely.
4. Issues in Case Recording
In addition to ensuring the principles above underpin case recording, other areas to consider include:
- the adult’s voice should not be ‘missing’ from the case record: whilst actions taken in relation to them are documented, their wishes, feelings, views and understanding of their situation should be recorded. There may be a tendency to focus on the views of a carer who is able to be more vocal, rather than the adult who may have more difficulty in expressing themselves;
- the size of the record may make it difficult to manage: records should be focused and important information highlighted and regular summaries / transfer summaries included to make it easier to find for others reading the record;
- a completed assessment should be on file: information must be analysed and a plan created for the assessment to be complete. An assessment is not just about collating information;
- the record must be written for sharing: making it easy for the adult to read and understand. Language should be plain, clear and respectful, keeping social work terms to a minimum. Records should be shared regularly with the adult to encourage them to contribute to the record;
- the record should be used as a tool for analysis: it should not simply record what is happening, but also to analyse and hypothesise why particular situations and events are occurring. The use of genograms, chronologies and assessment records can help organise and analyse information.
Issues for managers and policy makers can include:
- ensuring sufficient management action to support recording policies and procedures: audits of case recording should be regularly conducted to identify good practice as well as areas of concern, which should be discussed in staff supervision sessions (see also Audit Cycle);
- policies and procedures should be sufficiently detailed to support staff: they should state what records need to be completed and when; they need to be relevant and staff adhere to them; social work practice and recording should be integral and not seen as separate issues;
- recording is not an integral part of performance monitoring: it should be referenced in job descriptions and on agenda items in staff induction, supervision and performance development reviews;
- policies, procedures and practice tools should be developed and implemented with the involvement of practitioners: new developments should be informed by staff views of their expertise – staff involvement in developing policies, procedures and guidance is essential. (see Staff Engagement);
- systems should be developed or reviewed to ensure the same information is not requested multiple times. This saves the adult / carer from being repeatedly asked for the same information, as well as staff time and resources.