Whether you are a social worker, counsellor, foster carer or lead children's/youth activities you will need to keep records. Marian presents some tips which we hope you will find useful.

Some general points about record keeping

Introduction - a personal lesson

Some years ago I was requested to be a witness in court during a Care Proceedings Hearing, in regard to the physical abuse of a baby. When I was asked to describe the injury, I had a picture in my mind of the bruise on the baby's cheek, but I did not have a written record or drawing of the actual shape and size.... How I wished that I could have said “it was oval in shape, approximately 4cm by 5cm”, or have shown a written diagram. My attempts to describe from memory and show the shape/size with my fingers weakened my evidence, as I was unable to give an accurate account. In wanting to help others to avoid my mistake, and to comply with a plethora of legal expectations, I offer some guidelines.

Who should record?

It is difficult to cover all activities / roles involved with children where records are kept If you are a social worker, nursery nurse, teacher, foster carer, nurse, doctor, children's guardian or solicitor, then record keeping is an essential part of your work and the practical / legal requirements are normally covered during training. But for others, volunteers at children's and youth camps, or those involved in children's activities at church, little or no training my be given. So read on.

Why do it?

McMahon (1) suggests that there are a number of specific purposes for keeping records including the following:

• as a memory aid
• to monitor clients progress
• for administrative reasons
• to aid process of referral
• for training/accreditation purposes
• to assist therapeutic audit
• for legal reasons
• for an internal complaints procedure
• as a tool for reflection

Martin Shaw (2) who has researched and written on residential care, adoption and foster care has identified similar purposes:

Client related purposes:

• case memory - basic data; what happened to whom, when
• build up a moving picture and help in problem solving
• monitor progress and development

Agency purposes:

• monitor what is done and establish accountability
• ensure compliance with agency policies
• show gaps in services; tool for supervision/staff development

Worker related purposes:

• enable worker to "think aloud"
• cover selves
• assessment of professional development

Other purposes:

• providing teaching material
• providing research data

There are legal requirements, too, e.g. Access to Personal Files Act 1987, Children Act 1989, Adoption Agencies' Regulations 1983, Adoption Rules 1984. These state that records must be kept, and define what needs to be recorded, and how.

What should be recorded?

What is recorded must be linked with who it is that is making a record, the context and why. A check list derived from these guidelines and others would suggest the need for:

• entries to be signed and dated
• name of signatory to be clearly identified
• adherence to professional standards

information to be:

• factual
• accurate
• clear
• records/files to be stored in a safe place which ensures confidentiality

How to record?

With the increasing emphasis in allowing individuals the right of access to their records, attention needs to be paid to how records are written - that takes skill. Martin Shaw suggests that records should be written:

as if the client were there looking over your shoulder. It is only a short step from that to writing with the client alongside, commenting on, amending, supporting the report, perhaps adding a dissenting note of their own. Records then become a co-operative experience in the 'partnership' spirit of the Children Act. (2)

Putting aside the fears and establishing/maintaining records that can meet all the criteria for access, Shaw (2) further suggests some principles in open recording:

• Information gathering - we should be seeking and recording only information necessary for that purpose
• Distinguish facts from opinions
• Distinguish personal values
• Be concrete and specific rather than abstract and generalised
• Use simple language
• Positive recording - it is better to emphasise strengths and positive steps that can be taken to improve a situation rather than settling for a static, pathological view of the client and his or her world
• Recording is part of practice

Conclusions

For many, record keeping is an aspect of work that takes a lower priority than perhaps direct work with a child. Yet it is a key aspect in assisting us both in recalling detail and providing a factual record that could be retrieved at a later date. How I wish that I had drawn a diagram of that bruise, with a note of estimated size!

Bibliography

1. "Practical approaches: note-taking": G. McMahon (1994) "Counselling, 5" 1994.

2. "Avoiding the Pitfalls - Good practice in record keeping" - Martin Shaw - BAAF Selected Seminar Papers 1994/95.

"The Children Act 1989 Guidance and Regulations, Volume 2 - Family Support, Day Care and Education Provision for Young Children": HMSO

“The Act requires providers to keep records of the children attending a day care service. This requirement is confined to factual details about the child and his parents. It is also important that people working with young children in a full day care setting observe what each child within the facility is doing, assess what this means in terms of learning and development, report and record it.”

 

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