A record should be made of key decisions and information that fully reflects the child protection enquiry process.
be contained within specific formats in the relevant electronic system;
be signed, or the author identified, timed and dated;
should record contacts with the child including what the child says in the child’s own words;
follow agency/professional codes of practice in relation to record keeping
ensure correct names, addresses and dates of birth.
be factual and evidence based. For example, draw on observations, the child and /or parent’s own words.
Include professional opinion but these need to be supported with the evidence or observation on which they are based.
All agencies need to:
ensure that staff members and professionals are aware of their agency’s standards required for record keeping;
have a system in place for monitoring recording standards. Health should ensure that within a given location, there is a single set of records for the child;
ensure clear protocols are in place concerning information databases and in particular the content, process and access to records that are maintained by agencies in respect of individual children.
N.B. Practitioner’s rough notes are evidence of what was written at the time. Therefore, they should not be destroyed when the details are recorded more formally but kept securely in case they are required in any subsequent legal proceedings.
Social services recording should include: