Recording and report writing are important aspects of your work with service users and carers. They should not be regarded as detracting from direct work since they are an integral part of good practice.
Recording and report writing are important because they set down in writing evidence of your work to meet service user’s needs, implement care plans and meet organisational requirements. They assist continuity when workers are unavailable or change.
Good records and reports can help you to reflect on and improve the work you do with service users and carers and can support effective partnership with service users, other people, team members and other organisations.
Good records and reports should:
- Be written clearly and legibly, avoiding jargon
- Pay attention to spelling and grammar
- Keep to the point, ensuring relevance
- Avoid duplication
- Be accurate
- Record dates, times and names of the writer and other key people
- Be up to date. Try to write records ‘there and then’ rather than delaying them to another time or day
- Be shared with service users wherever possible and appropriate, enabling them to contribute to and understand records and reports that concern them
- Distinguish opinions from facts and avoid unnecessary labels and judgements
- Record and report any signs and symptoms that may indicate a change in the condition and/or care and support needs of the individual
- Maintain confidentiality by keeping records and reports in a safe, secure place. If these are on a computer, there should only be access for those with permission, via a password secured system
- Only be shared appropriately, while respecting confidentiality
- Follow legal and organisational procedures in relation to recording and reporting.
Excerpt From: SSSC Digital Learning. “Communication and relationships”. Scottish Social Services Council, 2020. Apple Books.