Session Three
     Record Keeping 
          &
      Documentation
      Session Three - Aims
    • The consider the importance of accurate and 
     comprehensive documentation in the service 
     user file.
    • To understand how to record service user  
     activities within a Reabling context. 
              Why Record?
      •Legal requirement 
      •To ensure continuity, consistency and high standards of care
      •To ensure effective communication of information relating to the service user 
      between all members of the team
      •To monitor progress and inform review team
      •Courts of Law and Complaints Tribunals tend to adopt the attitude
           “If it has not been recorded - it has not been done!”
               “Shoddy records = Shoddy care” 
       Effective Documentation
      Should be:
     •Accurate, factual
     •Is consecutive - Contemporaneous (written asap) & chronological 
     •Not jargon or meaningless phrases or text style abbreviation
     •Date and time, chronological order,
     •Legible handwriting black ink
     •Signed 
     •Free from speculative / opinion-based statements 
     •Free from humour / sarcasm 
     •No blank lines 
        Principles of Good Record 
                 Keeping
     Errors, Alterations, Additions
     • Dated and Time-stamped (24 hour clock) 
     • Signed in full (no initials) 
     • Crossed out with a single line (errors only), so original entry can be read 
     • No correcting fluid 
     • No falsifying of information i.e. do not write notes and sign on behalf of 
      others.