Recording Policy and Guidelines

The child's record is an important source of information for them as well as a tool for planning actions and interventions. It provides information about the sequence of events which brought about Children's Social Care's intervention into their life and provides an explanation for the reasons why important decisions were made in the child's and/or family's life. The case record can be key to helping a child understand themselves and their past – especially where the child was unable to live with their parent/other long term carer.

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.

All records, irrespective of whether they are physical or electronic, should be securely kept and electronic messaging (e.g. e-mails) should also be sent in a secure and safe way so as to preserve their confidential and professional nature, (see Section 13, Records Should be Kept Securely).

The child's case record 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.

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'.

A manager must approve the design of all records and forms before coming into use.

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 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 has made the decision and the basis on which it has been made.

See also: Section 10, Records Must be Written Clearly using Plain Language and Avoid Prejudice and Section 11, Records Must be Accurate and Adequate.

Every child's case record must hold details of the child's full name, date of birth and any identification number. Care should be undertaken to ensure the spelling of names is accurate and where possible, evidenced e.g. birth certificate. In some instances, key information may change and it is important the record should identify the current circumstance of the child / family.

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.

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. The child should have the opportunity to have support to be able to do this if needed, through an Advocate and / or through specialist help, e.g. a signer.

It is recommended that any contribution the child may wish to make, any written material, certificates etc should be included on the record as copies, so that the child retains the original items so that they have their own record of their wishes, progress etc.

Children and their parents must be asked to give their agreement to the sharing of information about them with others Information should be shared with the consent of the child and family if appropriate and where possible the wishes of those who do not wish confidential information to be shared should be respected. Information can still be shared without consent if it is in the public interest to do so. Information sharing decisions should be based on consideration or the safety and well-being of the person and others who may be affected by the sharing.

In such circumstances ensure that the information shared is necessary for the purpose for which it is being shared and shared only with those who need to have it.

Information contained in the case record should usually be shared with the Data Subject 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 after taking advice from a manager.

See also Access to Records 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 Procedure.

Records should be updated as information becomes available or as decisions or actions are taken as soon as practicable or, at the latest, within 24 hours of the event.

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 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 24 hours of the event (see also: Section 1, Records Must be Kept on all Children).

Records must be written clearly and concisely, using plain language, and in a way that recognises the right of the child or their parent/carer will access the record (whether whilst the case is active or at some point in the future).

E-mail communication to colleagues and other professionals (that will be included in the record) should always be completed with the same care and attention. 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 technical or professional terms, acronyms and abbreviations must be kept to a minimum; and explained.

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.

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 Access to Records Procedure and Case Records and Retention Procedure.

See also The Wordinary: a Language Guide for Professionals Working with Young People.

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. If a child / young person feels that information in their record is not accurate, they have a right to request that it is rectified. Local authorities have 1 month to respond to any such requests and, if any such request is received, the authority should take reasonable steps to establish if the data is accurate and rectify the record if necessary.

Records must distinguish clearly between facts, opinions, assessments, judgements and decisions. Records must also distinguish between first hand information and information obtained from third parties.

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.

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 have access to.

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

All electronic records must be kept securely and comply with the requirements of the Data Protection Act 1998. This will include arrangements such as:

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

Where staff are working in an 'agile' / 'mobile' / 'hot-desking' context, care must be exercised to ensure that records or computers are not left on or overlooked by others.

Staff using computers 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 (1998). 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.

Should the situation ever occur where a laptop is lost or mislaid, the local authority officer must report this immediately to their manager and every reasonable effort should be made to obtain their recovery.

Consideration should be given as to whether service users should be advised of such an event.