Good record-keeping is an essential part of care work. Carers need to communicate with each other on a daily basis. They need to let each other know what has happened on their shift. When the shifts change, we need handover communication meetings in order to highlight the day’s events. We use communications books or daily progress which must be written within the guidelines of positive record keeping. Records are kept to ensure good and consistent care and to help staff work together. Records can be used to evidence that tasks have been completed or let other staff know about service users’ experiences, needs or events.
You need to know how to record information appropriately. Records are official documents and contain important information. They may be read by different people, including other staff and inspectors. You need to ensure that what is written is legible, accurate and respectful of anybody referred to.