Any records you keep such as an individual’s care plan must be up to date, complete, accurate and legible. Records are an important tool of communication between yourself and others who are involved in providing care and support. They contain important information that others can use to ensure quality and consistency of care. They may also become legal documents of evidence if there is cause for concern.
As such, you should include all necessary details in the document, write tidily in a way that is clearly understood and avoid jargon. Information should be factual and not based on opinion. If you need further support with properly keeping records, ask your employer to share examples of records such as care plans with you and talk you through how they should be completed and what they should contain.