Unit name: Handle Information in Care Settings
Learning outcome: 3. Be able to handle information in accordance with agreed ways of working
Assessment criteria: 3.1 Keep records that are up to date, complete, accurate and legible
All records that you keep must be up to date, complete, accurate and legible. This is because also records are legal documents and may be used in future investigations.
Records that are up to date are regularly reviewed so that any changes can be documented. A good example is care plans – these must be updated regularly to reflect an individual’s changing needs, preferences and wishes. There should be an audit trail of any changes and all changes should be signed and dated.
All records should be complete. This means that should be comprehensive, with no essential information missing. If records are not complete, the people that read them may have to fill in the blanks themselves, which could result in them drawing erroneous conclusions.
Similarly, all records should be accurate. This means that they should be true and factual. Objective prose must be used that is factual and does not contain the thoughts, views or feelings of the person writing.
Finally, it is essential that records are legible. This means that they are written clearly so that others can comprehend them. If you have messy writing, you should take your time and write in block capitals.