Documentation and Record Keeping

Care records do three jobs at once. They hand the person safely to the next shift ("ate little, drank 600ml, low mood after his son's call — try the garden after lunch"). They evidence that planned care happened. And when something goes wrong — a safeguarding enquiry, an inquest, a complaint — they become the service's memory under oath, read line by line by people looking for the truth years after everyone's recollection has faded.

That's why the standards are strict and simple. Write soon after the event, while it's true in your mind. Write facts: what you observed and did, what was said (quote it), amounts and times. Keep judgements out — "aggressive all shift" tells a tribunal about your patience; "at 14:20 threw beaker at wall when music turned off, settled after 10 minutes in quiet lounge" tells everyone what happened and even hints at the fix. And never, ever write care as done before it's done — pre-signed charts have ended careers, because the one day the visit doesn't happen is the day the chart says it did.

Good records also carry respect. The person may read them (they have the right); their family may read them after a death. Write about people the way you'd want your mother written about — honestly, warmly where warmth is true, never mockingly, never in lazy shorthand that shrinks a person to a task list.

• Regulation 17(2)(c) (2014 Regulations): providers must maintain an accurate, complete and contemporaneous record for each person, securely kept.
• UK GDPR and Data Protection Act 2018: care records are special category data — lawful basis, security, accuracy, minimisation, retention limits, and people's rights of access (see the Confidentiality topic).
• Records Management Code of Practice for Health and Care 2023: the reference for retention schedules — for example, adult social care records commonly kept for years after care ends; check the current schedule rather than guessing.
• Duty of candour (Reg 20): written follow-ups after notifiable incidents are themselves records.
• Records may be disclosed to courts, coroners, CQC, safeguarding enquiries and ombudsman investigations — they are written for those audiences whether anyone intends it or not.

Record-keeping failures are among the most common Regulation 17 findings. Assessors look for: notes matching charts matching plans (fluid targets actually totalled and acted on; repositioning charts that vary like real life); gaps explained; body maps for every mark; PRN effect recorded; and — in digital systems — logins used properly (no shared accounts), times reflecting reality rather than end-of-shift bulk entry. They also read tone: notes that respect people. "Refused care" three times daily for weeks with no review tells CQC the records are working but nobody is reading them — which is its own finding.

• Structure notes so nothing is missed: many services use headings or prompts — care given, food and fluids, continence, skin, mood, activity, concerns, actions. Whatever the format: specifics, amounts, times.
• Quote significant speech verbatim: disclosures, refusals, wishes ("I don't want the hospital, whatever happens"). Quotes are gold in safeguarding and capacity work.
• Time entries honestly. If you write late, say so: "Entry made 21:40 re events at 14:00" is professional; back-timing is falsification.
• Corrections: single line through the error, "written in error", initial, date, correct entry follows. Digital systems keep audit trails — never share logins, never let anyone else post as you.
• Mind the language: "declined" not "refused to comply"; "needed encouragement" not "difficult"; behaviour described, not diagnosed ("shouted and paced" not "kicked off").
• Handovers are records too where written — and the same standards apply to messages in approved apps. Never move care information through personal phones or unapproved channels.
• Store and move records securely: folders not left in cars overnight, screens locked, home-care records balanced between accessibility in the house and the person's privacy from visitors.

Example 1. Two years after the event, a coroner examines the death of a man who deteriorated overnight in a care home. The night worker's note reads: "02:15 — checked, breathing settled, colour normal. 04:30 — restless, RR counted 22, skin clammy; called 111 per escalation plan, advised ambulance; 04:52 ambulance arrived." Court concludes the worker did everything right, quickly — provable only because she wrote it at 04:55, not because anyone remembered.

Example 2. An audit finds a home care worker completing all six of a day's MAR signatures at the final visit "to save time". No harm occurred. The manager treats it as the serious finding it is: retraining on contemporaneous recording, a period of spot checks, and a team briefing on why the habit is dangerous — the day a visit is missed, pre-signed records make an honest mistake look like deceit. The worker, to her credit, becomes the team's fiercest advocate for writing it when you do it.