Why is good documentation important?

It’s important to keep high quality records. Poor record keeping has been identified as one of the main safeguarding challenges, and can have a harmful effect on both safeguarding adults at risk of neglect and abuse and the staff involved, as shown in several examples in Safeguarding Adults Reviews (SARs).

Good documentation is also about sharing information with organisations, agencies and healthcare professionals involved when there are safeguarding adults concerns. Information sharing is very important for effective safeguarding, identification, assessment, and risk management.

Registered healthcare professionals must be clear about when they should share information, and recognise the signs and triggers of abuse and neglect in people who are at risk.

Good record keeping is very important so that organisations and agencies are able to prove how decisions were made legally and safely. Documentation in the safeguarding adults process is essential in providing supporting evidence when making referrals to other organisations, such as the Local Authorities, Disclosure and Barring Services (DBS), Care Quality Commission (CQC) and coroners court. Good record keeping is an integral part of safeguarding practice for all healthcare professionals.

All organisations, agencies and registering bodies should have their own professional guidance on record keeping which healthcare professionals must abide by.

When a safeguarding adults concern is escalated, each service or organisation should have clear and accurate records to share. It is important that all records are stored in accordance with the organisation’s policies and procedures with regard to the Data Protection Act 2018.

Why do we need to keep records?

The importance of good, clear safeguarding record keeping is identified as essential practice within statutory guidance in adults safeguarding. Documentation may include reasons for raising a safeguarding concern, discussions that have taken place, and what safeguarding decisions were made. Registered healthcare professionals should discuss their concerns about recording requirements with their line manager or their safeguarding supervisor.

Accurate and up-to-date recording of safeguarding concerns is important for several reasons:

• Concerns and patterns of abuse are identified at a very early stage.
• It can help inform the Safeguarding Adults Review (SAR) process.
• It assists with Section 42 safeguarding enquiries when a concern is raised.
• It helps organisations to monitor and manage safeguarding practices which include decision making, and what actions were taken jointly.
• It provides evidence to support professional dispute and disagreements when working with external organisations.
• It provides evidence for actions that have been taken to reduce impact of harm to an adult at risk.

Principles of good record keeping

Best practice in record keeping is based on transparency, openness and accuracy. Good quality record keeping is essential to ensure that:

• there is continuity and consistency of service delivery to the adults at risk at all times
• robust risk management practices are in place to safeguard the adult at risk, especially in emergency situations
• one can demonstrate clearly how decision-making in relation to the mental capacity assessments has been completed, and the rationale if a Best Interest Decision has been made
• there is evidence of partnership working involving the adults at risk (in making safeguarding personal), family members and other healthcare professionals
• healthcare professionals have access to up-to-date information to support decision making
• the adult at risk and their family members/carers with specific communication needs receive appropriate care and support. This could apply to many healthcare problems or situations, one example being an updated hospital passport for people with learning disabilities when they are admitted to hospital.