Recording Policy and Guidelines

The child's records will usually be developed from notes taken in the course of a visit or interview and these may be used directly, or as a result of such information being in a report or court statement. The Family Court, in the case of RE M and N (Children) (Local authority gathering, preserving and disclosing evidence) advised that social workers/practitioners must make contemporaneous notes which form a coherent, contemporaneous record. The notes should be legible, signed and dated and record persons present during the meeting/conversation in question. The notes should be detailed and accurately attribute descriptions, actions and views etc. In some instances, sketches/diagrams may be helpful in establishing the veracity of explanations given, e.g. with regard to how injuries were sustained, etc.

Note: These original notes might need to be disclosed in a court.

Each child must have his or her own electronic case record from the point of referral to case closure; audio, video and digital recordings may also be kept.

Where paper files are also kept, information held in electronic records must accurately reflect the corresponding information recorded within paper files.

Records held on paper may extend to more than one volume. Where more than one volume exists, the dates covered by each volume must be clearly recorded on the front cover.

Records and forms must be designed to fit their purpose and used consistently across the organisation. The design should be flexible and promote ready distinction between historical and current information and not rigidly seek to reflect a presumed social work 'workflow'.

All records and forms must be approved by the appropriate management group before being implemented.

Children and their families should be told what types of information/data is contained in their case records.

In particular, they should be helped to understand what data is collected on them, how it is used, who it might be shared with and how long it will be kept for. The most common way to provide information to Data Subjects on what data is collected and how it is used is through a Privacy Notice. Privacy Notices must be easily accessible to children, young people and their families, and should be part of the induction pack given to any new staff members.

See Confidentiality Policy and Access to Records / Subject Access Requests Procedure.

Where children have been adopted, see also: Access to Birth Records and Adoption Case Records Procedure.

Information must be provided in a form that children and their families will understand - in their preferred language or method of communication. An interpreter will be provided if needed.

The practitioner primarily involved, that is the person who directly observes or witnesses the event that is being recorded or who has participated in the meeting/conversation, must complete records.

Where this is not possible and records are completed or updated by other people, it must be clear from the record which person provided the information being recorded. Preferably the originator should read the record to ensure its accuracy.

Records of decisions must show who made any decision as well as the basis on which it was made.

See also: Section 11, Records Must be Written in Plain English and Prejudice Must be Avoided and Section 12, Records Must be Accurate and Adequate.

Every child's record must hold details of the child's full name, date of birth and any identification number, taking care to ensure the spelling of names and other details are accurate and where possible, evidenced.

It must also include a case summary, genogram, risk assessment, transfer/closing summary (where appropriate) and a properly maintained Chronology.

All other relevant contacts with children, their families, colleagues, professionals or other significant people must be recorded in the same way, i.e. who was present or seen, the relevant discussions, actions or decisions taken and by whom, and the reasons for decisions.

Other professionals and partner agencies providing information/reports should be made aware that information provided by them may well be included on the child's file and that this could be accessed by them (Note: care should be undertaken to ensure a breach of the Data Protection Act 2018 does not occur through the inclusion of information about others via reports and e-mails, etc.)

Children and their families must be routinely involved in the process of gathering and recording information about them. They should feel they are part of the recording process.

They should be asked to provide information, express their own views and wishes, and contribute to assessments, reports and to the formulation of plans. These views should be clearly recorded within relevant documents and case records, noting for children who have communication difficulties, what support was available and/or how these views were gleaned.

The quality of the relationship between the social worker and the child should also be noted.

Generally, they must be asked to give their agreement to the sharing of information about them with others - but there are exceptions which are identified in the next section.

Information obtained about children and their families should be shared with them unless:

• Sharing the information would be likely to result in serious harm to the child or another person; or
• The information was given in the expectation that it would not be disclosed; or
• The information relates to a third party who expressly indicated the information should not be disclosed.

Where information is obtained and recorded which should not be shared with the child concerned for one of the above reasons, it should be placed in the 'Restricted from user' section of the child's record and the reasons should be recorded.

See also: Access to Records / Subject Access Requests Procedure.

Where children have been adopted, see also: Access to Birth Records and Adoption Case Records Procedure.

When sharing a record it is important to record who it was shared with and when. The sharing of all decision-making documents such as assessments, care plans, reviews, reports and agreements make it easier for everyone to know what is expected and to work together better.

Managers must monitor confidential information held on the 'Restricted from user' section of case records, ensuring that the reason for it being considered confidential is valid; if not, it should be available to be shared with the child.

However, before sharing any such information, the manager must take all reasonable steps to consult the originator and take account of their views and wishes. See also: Access to Records / Subject Access Requests Procedure.

Those completing electronic records must show their name and the date when the recording was completed.

If possible, paper records should be typed or handwritten in black ink and all such records must be signed and dated and scanned into the electronic file.

Any handwritten records must be produced so that readers not familiar with the handwriting of the writer can read the records quickly and easily. It must be possible to distinguish the name and post title or status of the person completing the record. If there is any doubt of the identity of the writer from a signature, the name should be printed.

Children's Service staff are expected to transfer information from paper notes, relevant e-mails and text messages to the electronic case file within two working days, or within 24 hours of a significant event in the child’s life.

Records should be updated from detailed notes made contemporaneously following a visit or interview; as various information becomes available or as decisions or actions are taken as soon as practicable or, at the latest, within two working days, or 24 hours of a significant event in the child’s life.

(see also: Section 1, Records Must be Kept for all Children).

Where records are made or updated late or after the event, the fact must be stated as a 'Late Entry' in the record, and the date and time of the entry should be included.

Records must be written concisely, in plain English, and in a way that recognises the right of the child or their parent/carer, should there be access to the record (whether whilst the case is active or at some point in the future). It must not contain any expressions that might give offence to any individual or group of people on the basis of race, culture, gender, gender reassignment, religion or belief, age, disability, or sexual orientation.

Use of technical or professional terms and abbreviations must be kept to a minimum; and if there is likely to be any doubt of their meaning, they must be defined or explained.

Care must be taken to ensure that information contained in records is relevant and accurate and is sufficient to meet legislative responsibilities and the requirements of these procedures.

Every effort must be made to ensure records are factually correct.

Records must distinguish clearly between assessments, judgements and decisions. Records must also distinguish between first-hand information and information obtained from third parties. Records must reflect the distinction between fact and opinion. Although it is admissible to record opinion, it must be recorded as such and not presented as factual.

The recording should seek a proportionate balance to reflect positive and negative aspects of a child or family's life.

Note: whilst 'cutting and pasting' techniques are generally not recommended, on those occasions where it is used, great care should be given to ensure that other parties' details are not included and that the context of the recording is appropriate and proportionate, (e.g. events that occurred some time ago do not reflect a current tense or disproportionate sense of relevance).

See Confidentiality Policy.

The overall responsibility for ensuring all records are maintained appropriately rests with line managers, although the responsibility can be delegated to other staff as appropriate.

The line manager should routinely check samples of records to ensure they are up to date and maintained as required and, if not, that deficiencies are rectified as soon as practicable.

14. Records Should be Kept Securely

All records held on children must be kept securely.

Children's paper files should normally be stored in a locked cabinet, or a similar manner, usually in an office which only staff / carers have access to.

Other day-to-day records, such as Contact or Daily Records, should also be kept securely in a manner authorised by the manager and in line with Data Protection legislation.

These records should not be left unattended when not in their normal location.

All electronic records must be kept securely and this will include arrangements such as:

• Password protection;
• Automatic log out of screens;
• Logging off computers;
• Changing passwords on a regular basis.

Records should not normally be taken from the location where they are usually kept.

If it is necessary to remove a record from its normal location, a manager should approve this and should stipulate or agree how long it is necessary to remove the record. The manager must also be satisfied that adequate measures are in place to ensure the security of the record(s) whilst they are removed. For example, records must never be left in unattended vehicles.

The authorisation for a record to be removed must be recorded and those who may have need to see the records should be informed of their removal. The manager must then ensure the record is returned as required/agreed and a 'sign in/sign out' system must be used.

Where records are moved to a new location, the date of transfer should be clearly recorded.

The sender should check that the records have arrived at their intended destination.

The member of staff responsible for the case when involvement with the child ends is responsible for ensuring that the file to be retained is in good order and that unnecessary items have been removed, for example, compliment slips, duplicate copies etc.

Staff using laptops at home for work purposes must ensure that they are working within the rules of the 'data protection principles' in accordance with the Data Protection Act (2018). Staff are required to familiarise themselves with the local information security policy.

This applies to staff using laptop computers and mobile devices in the course of their duties.