Recording in Daily Records/Daily Logs/Daily Journals
Norfolk County Council has recently had a complaint investigated by The Local Government Ombudsman. One of the outcome actions agreed with Ombudsman is that the council would remind all care providers to ensure daily care records accurately reflect each visit, including any negative incident care experience.
The complaint related to a situation where care was not delivered in accordance with the agreed plan. For example, incidences where visits were shorter than expected, or where agreed tasks could not be completed or were not delivered at all.
CQC’s Key Line of Enquiry requirement:
S2.3 Are people’s records accurate, complete, legible, up-to-date, securely stored and available to relevant staff so that they support people to stay safe?
It is important that care workers accurately complete the daily logs. People who use services have the right to see our information about them. Other care workers read what we write to understand the person’s care needs. Care review meetings base care decisions on what we write. What we write may be (and often is) used in complaints, investigations and legal cases.
Care notes should be:
- Timely: done as soon as possible (while fresh in our memory)
- Easy to read: clear handwriting, accurate spelling, black ink (it photocopies well)
- Dated, timed and signed (by both carers if two carers are present)
- Complete: all the necessary information
- Accurate: correct details (names, times, dates etc)
- Clear: plain English that everyone (including the person) can understand, no abbreviations, no jargon
- Factual: just what happened, no opinions, comments, assumptions or guesswork
- Respectful of the people in our care: no judgements, no personal comments
Skills for Care has produced some guidance on writing reports, including daily notes. This guidance can be downloaded here: https://www.skillsforcare.org.uk/Documents/Learning-and-development/Core-skills/Learning-through-work/Reporting-and-other-care-work-writing.pdf
Head of Quality Assurance & Market Development