Recording Policy and Guidance

1. Purpose of Recording

Records are primarily for the benefit of children and families that we work with and should be an accurate account of the contact or activity with the child and their family.

Effective recording cannot be underestimated; it is a tool that facilitates good social work practice and also demonstrates the complexity and amount of work being undertaken. Best practice dictates that managers regularly use recording to monitor and ensure that work is meeting requisite standards.

Effective recording also fulfils a variety purposes to include:

• Forming a biography, for example to show someone's history;
• Evidencing the views of children, families, carers and professionals and how this informs decision making;
• Ensuring accountability and transparency in service provision;
• Providing a documented account of involvement with children, families and carers;
• Keeping the work of all practitioners focused and supporting effective partnership working with children, families and other professionals;
• Enabling all staff to reflect upon the quality of the service provided and make plans regarding any future services required;
• Ensuring that important information is not forgotten and providing an evidence base that explains the rationale behind past and proposed professional decisions, intervention, planning and review
•  Providing evidence in response to complaints, investigations and other enquiries;
• Allowing for continuity in service provision by supporting 'seamless' working when multiple personnel are involved with a child or family or when personnel change;
• Evidencing that information sharing, for example providing copies of assessments, plans and minutes of meetings, with children, families and professionals occurs as appropriate;
• Ensuring consistency in the way information is collected to facilitate wider scrutiny and analysis of services (for example through audits or research), inform service priorities and provide information that allows the local authority to meet its statutory reporting requirements for example, the Children in Needs Census and Children Looked after Returns.

2. Good Practice Principles

DO's…

• Be clear about why you are recording;
• Record who you are, type your name, the date, time, place and people involved;
• Be clear about fact, observation and professional opinion;
• Be clear about what is third party information and any issues of confidentiality;
• Record disagreements by service users, contentious issues and complaints;
• Explain how decisions were made, who was involved and any other views;
• Cross-reference (i.e. letters, emails, risk assessments, etc.);
• Refer to people by their name and title initially;
• Remember before you start writing that people have the right to access to their records;
• Complete recording as soon as possible and within the required timescales (see 6.);
• Completing regular summaries can be a good way of monitoring the person's progress;
• If there are safeguarding issues, remember to record the incident using the individual's words to describe the incident;
• Only record a person's mood and behaviour if this is part of an agreed care plan/ support plan or relevant to the situation.

DON'T…

• Use jargon and unexplained abbreviations;
• Use language that is discriminatory and judgemental;
• Amend at a later date;
• Make assumptions.

3. Standards in Recording

The following standards will apply in respect of all recording:

• Entries should be structured, using subheadings and paragraphs to assist with the clarity and understanding of what is being conveyed;
• All significant contact with children, families, colleagues, professionals or any other relevant people must be recorded in the same way, that is, who was present or seen, the key points from the discussions had, actions taken or decisions made by whom and the reasons for the decisions;
• Records should be secure and confidential, and should only be accessed by those who have professional interest or authorised to have access or those professionals external to the Local Authority who are authorised within a legal framework;
• Recording must be accurate, appropriate, and timely, with all sources of information identified;
• Records must clearly identify who has Parental Responsibility for the child and where there are any interim arrangements for a child's care, for example temporary placement with a relative or in foster care, these arrangements much also indicate who has decision making responsibility for the child, on what basis and for what duration;
• Records must evidence consideration of equal opportunities, diversity and social inclusion issues;
• Purpose of visits to children and their families should be clear; the visits should succinctly record the main points and any actions for follow up. Records should confirm that the child has been seen and efforts made to communicate with child or observe (taking into account the needs of the child) must be stated. Records should demonstrate how the child's views were used to inform decision making;
• All documents must have a title and appropriate classification before being uploaded on Mosaic to assist in later retrieval;
• Inappropriate documents or conversations should not be stored or cut and pasted onto the child's record. For example, emails that include personal conversations about holidays, social life or personal disagreements should not be stored on a child's file;
• Where  children/ families are to be transferred to another worker a transfer summary must be completed providing overview of progress, plans and outcomes sought and for children/ families being closed, a closing summary must be completed giving clear reasons why a service, at a safeguarding level, is no longer required for the child or family;
• Generally, children and families must be asked to give their agreement (consent) to information being shared about them with others - but there are exceptions for example:
  1. Where sharing the information could likely result in serious harm to the child or another person;
  2. The information was given in the expectation it would not be disclosed;(for example information shared by police but which cannot be disclosed to children or families because of on-going police investigation);
  3. The information relates to a third party who expressly indicated the information should not be disclosed;
  4. If you have any queries/ concerns about information sharing, practitioners need to discuss them with their line manager in the first instance; if the queries remain, they can consult the Caldicott Guardian (Darren McAughtrie Corporate Director, Adult Care & Quality Standards; Caldicott.Guardian@walthamforest.gov.uk)
• Any communication between the practitioner and the child/ young person/ parent/ carer that uses digital technology, such as "skype", "WhatsApp", text messages, or any other platform needs to be uploaded onto their Mosaic record as a screen shot.

4. Use of Language & Recording Style

Plain English Principles should be observed consistently in recording. Plain English is defined by the Plain English Society as "A message, written with the reader in mind and with the right tone of voice that is clear and concise."

Additionally:

• The use of language and tone should be appropriate and suitable for the child and family members to read and understand;
• Recordings should be free from jargon and abbreviations should be explained when first used to ensure the reader can understand. Records should not include meaningless phrases, speculation, judgemental or offensive subjective statements;
• Records must not contain any expressions that might give offence to any individual or group of people on the basis of race, culture, religion, age, disability, or sexual orientation;
• Use of informal language is not acceptable. Spell check should be used for electronic recording;
• Information is presented in a concise manner so that it can be easily read and understood;
• Names and roles of professionals should be clear so that they are easily identified;
• Family information may be duplicated so long as it is relevant for each child;
• Chronologies must detail significant events in respect of child and history of involvement (see Section 5, Chronologies).

"Language that cares":

Waltham Forest Children's Services has made a commitment to using "language that cares" in all the recording in respect to the work with children, young people and their parents/ carers. This entails various aspects:

• Writing any records with the child/ young person/ parent/ carer in mind and the knowledge that they have the right to access their records;
• Using respectful language;
• Considering to write all records (where appropriate) to the child/ young person/ carer/ family, instead of about them; this also means that the author refers to themselves in the first person (i.e. "today I came to visit you, you greeted me by the door with a broad smile and were eager to show me your new cuddly soft toy tiger");
• Avoiding the use of professional jargon; where it is necessary to use, offer an easy to understand explanation (see the Family Right Group website for a good resource to explain professional jargon); see also: 'TACT Language that cares' that was co-produced with children in alternative homes (Children in care);
• Advocating the use of "language that cares" amongst colleagues and with professionals from other agencies.

5. Chronologies

A chronology written for any purpose is a record of key events, in a sequential order. It is based on a study of recorded information, and in social work practice its overall purpose is to support the analysis of the history of a child/ family with reference to the current state of work.

There are different purposes for writing a chronology:

• A chronology should frame your understanding of a service user and their family and tell the story of their lives. In this respect, they complement a genogram and ecomap nicely – the chronology describes the past while the ecomap describes their present, and the genogram overlaps with both;
• A chronology is a tool for a professional to use while working with a service user and professionals, and a tool for a service user to help understand their own life, and any relevant patterns – in other words, a wholly practice-based document;
• It also has a key role in assessments, as a point of reference for the completed assessment as well as an analytical tool to help create the assessment in the first place.

Significant Events – helpful tips:

• Focus on events and changes in circumstances that had a positive or negative impact on the child;
• Start from the date of birth of the most significant person to the child's story (this may be a grandmother or the parents);
• Only include any type of visit if something significant happened;
• Don't clutter the chronology by copying and pasting case notes or including lists of dates of visits;
• Multiple significant events may be grouped together i.e.: Between April – June 2012 there were 23 incidents of absconding which increased in frequency and duration each week, rather than listing all 23 separate incidents;
• If events are significant, they require a response – a chronology of incidents with no details of what was done raises questions about the SW involvement.
• If there was no action, explain why not;
• Where relevant, bring together information from a variety of sources and always identify the source;
• Always reference other documents clearly;
• Where there is an ongoing involvement with a child/ family their electronic record should have an up to date chronology and this should be a priority if one is missing or out of date.

What are significant events – this is not an exhaustive list:

Click here to view the Chronology template, WF and for court.

Some additional tips when completing the chronology template:

• The template should be used as a standard chronology for all electronic records;
• The template also meets the requirements set out by the courts as part of care proceedings;
• The source of the information needs to be included, i.e:
  • Referral received from school;
  • MERLIN received from police;
  • During home visit by the Social Worker it was observed that…, etc.
• The outcome/ decision taken needs to be clearly included, i.e:
  • Progressed to Child and Family Assessment;
  • Strategy meeting to be arranged;
  • Children made subject to a Child Protection Plan under the category of sexual abuse, etc.

6. Recording Timescales Table