Recording Policy and Guidelines
Scope of this chapter
'Good case recording is important to demonstrate the accountability of staff…it helps to focus the work of staff working in looked after children’s services to those who use those services… It ensures there is a documented account of the responsible authority's involvement with individual service users, families and carers and assists with continuity when workers are unavailable or change'.
Related guidance
North Yorkshire Children and Families Service adheres to the policies and guidance of our Information Governance and Records Management, which provides the context within which records are maintained and stored by our service.
All records held by the Children and Families Service will be accurate, appropriate, complete and stored safely. Each record will contain appropriate and a significant amount of information relating to the child/young person. This will then provide the basis for good decision making and assist colleagues also working with the family.
Where appropriate, children and their families/carers will be encouraged to contribute to the creation of their records, and file records will be easily accessible in all formats.
The child's record is an important source of information for them. It provides information about the sequence of events which brought about Children and Families Services involvement into their life and (in many instances) the reasons why important decisions were made in the child's and/or family' life. This can be a key feature for a child in understanding 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 ending the involvement; 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 15, Records Should be Kept Securely).
The information detailed within a child's 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 accuracy 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'.
Any changes to records and forms will be presented to the EHM/LCS/ContrOCC Development Group or Senior Leadership Team where they will need to be approved before coming into use.
Children and their families have a right to:
- Be informed about the records kept on them and the reasons why;
- Their rights to confidentiality; and
- To have access to their records.
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 allocated worker/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 and sign/endorse the record. These records need to be finalised on the LCS system.
Records of decisions must show who has made the decision and the basis on which it has been made.
See also: Section 12, Records Must be Written in Plain English and Prejudice Must be Avoided and Section 13, 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 case identification number. It is also encouraged that a photograph or selfie of choice of the young person is added to their record with their agreement.
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.
- Names and details of everyone who lives in the family home with the child, identifying the person who has Parental Responsibility;
- The name by which the child wants to be known and their legal name;
- If the child associates by a different gender to the one they were registered at birth this needs to be clearly recorded in line with their wishes and feelings;
- Where the child does not live at their home, the details of the Placement / arrangements and the legal status of the child;
- Names and details of anyone particularly close to the child with whom they spend a lot of time;
- Phone numbers and contact details of anyone significant;
- Information about the child and /or family's communication needs;
- A record of managers' decisions and reasons for making them;
- Supervision discussions with workers and managers should be recorded;
- Details of arrangements for family time if appropriate;
- Details and, where appropriate, copies of any Orders made on the child;
- Copies of reports provided during court proceedings, including specialist assessments, the Children's Guardian, etc;
- Any safety plans agreed with the family;
- Additional information about educational progress and where the child is Looked After, the PEP;
- Where a child has Special Educational Needs or Learning Disability, copies of any relevant information, including the Education, Health and Care Plan;
- Appropriate information about the child's health, and where the child is Looked After, a copy of the Health Plan and Assessment;
- Details of any arrangements for the responsible authority's functions to be undertaken by a private provider, e.g. an independent fostering agency or provider of social work services;
- Copies of all documents used to seek information, provide information or record views given to the authority in the course of planning and reviewing the child's case and review reports;
- Record of visits and contacts by all practitioners as well as by the allocated practitioner.
Each visit should be recorded to include:
- The venue of the visit;
- Who was present;
- The purpose of the Visit;
- Whether an interpreter was used;
- Whether the child was seen (and if not why this was the case);
- Information exchanged;
- A succinct narrative of the nature of the discussion;
- Any views the child expressed, noting for children who have communication difficulties, what support was available and/or how these views were gleaned;
- Any views expressed by the Parent/Carer;
- Identify whether there has been any significant change of circumstances for the child/or family, particularly membership of the household;
- Observations of the interactions and strengths within the family and celebration of successes;
- The quality of the relationship between the social worker and the child;
- An analysis and evaluation of the outcome of the visit, commenting within the context of the Plan and the Review Recommendations;
- Failed appointments and visits where there was no response should also be included, together with any actions required under the Children's and Families Services procedure guidance.
The Record must also include a risk assessment, transfer/closing summary (where appropriate) and a properly maintained Chronology, a genogram should also be included preferably a cultural genogram.
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. This includes conversations, phone calls, visits, letters, emails, decisions made by Agency Decision Makers/Panels, assessments and reports. The options that have been considered and the child and the family's preferred choices and the reasons why an option has been chosen if agreement could not be reached. (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 emails, etc.).
The child's record should also include relevant and appropriate copies of material from other, separate records/files that are kept, whilst ensuring that such records remain separate and that neither confidentiality nor the Data Protection Act are breached. It is recognised that a certain amount of cross-referencing with siblings is inevitable and desirable, but again, care should be taken in respect of sibling information that becomes available on the record. In the use of LCS and EHM ‘toggling’ of records should be used with caution.
The record should be structured and maintained in a way that:
- The decision-making process is clear;
- The views of the child, carers and/or those with Parental Responsibility can be found and related to the decision-making that has been made together with the responsible authority's actions;
- Any material temporarily placed in the record that belongs to the child should be noted as such so that it can be returned to the child when required / appropriate;
- Recording should be made of the Review meeting's recommendations / outcomes that are trying to be achieved with a child and their family, key tasks, by whom and timescales;
- The recording of interventions and actions should seek to identify which 'Recommendation' or Outcome they relate to;
- The recording should seek a proportionate balance to reflect strengths and successes alongside the worries in a child’s, young person’s or family's life;
- The structure of the recording should readily distinguish between current and historical events.
The Case Note Summary should be updated at a minimum on a monthly basis. Within this area workers are to maintain a simple summary of the family situation which contains essential information to be kept updated/recorded as a quick reference for when a case is transferred between workers and/or teams. This should be carried out in a Signs of Safety format and It would then also enable EDT to have a quick synopsis of the pertinent issues relating to a case in an emergency situation. This would then allow workers to have an instant brief without searching through forms/assessments in order to gain an overview of what is currently happening for the child/young person and their family. It is helpful to include in the summary the likes and dislikes of the child and any interests or hobbies which will enable any other workers who may have to visit a starting point of conversations.
Children and their Families should be Involved in the Recording Process.
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, wishes and feelings, 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. Mind Of My Own should routinely be used with all children and young people. See Mind of My Own leaflet for children and young people.
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 obtained about children, young people 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 restricted on LCS; in a paper file it should be placed in the 'Restricted' documents section and the reasons should be recorded after taking advice from a manager.
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/young person.
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 the pages numbered to assist in a reader being able to follow 'the child's story'.
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. Any handwritten records will need uploading to the child’s or young person’s electronic record.
Records should be updated from detailed notes made contemporaneously following a visit or interview; 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.
Records must be written concisely, in plain English, and must always be written in a way that recognises the child or their parent/carer will access the record (whether whilst our involvement is still current 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. The recording should certainly 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.
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 / Subject Access Requests Procedure and Case Records and Retention Procedure.
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 clear, concise and factually correct.
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.
Records must reflect the distinction between fact and hypothesis. Although it is encouraged to record our hypothesis, it must be recorded as such and not presented as factual.
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. There are also regular quality assurance activities that oversee maintenance of records, include thematic audits, and learning space conversations that help identify good practice as well as areas of improvement.
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. As soon as any paper documents are uploaded to LCS then they should be destroyed unless they are to be returned to the owner.
Other day-to-day records, such as Contact or Daily Records, should also be kept securely in a manner authorised by the manager.
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 2018. 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.
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.
Should the situation ever occur where a file / documents are 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. The service user should be advised of such an event. Such an incident should also be reported as per the Council’s internal data breach policy.
Where records are necessarily 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.
If records are moving because of a case transfer an audit should be carried out by a manager prior to transfer to ensure all relevant information and documents are available on the child's record.
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 (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.
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.
Last Updated: November 24, 2023
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