Record Taking

Paperwork and record taking is definitely up there as one of the worst parts of the job. I think this comes from the fact that a lot of us get into this type of work to support people, help and be there for them. Record taking and paperwork don't make us feel like that is what we are doing. It can feel a lot of the time like it is a task to complete so we can get back to the “real” work. Don't get me wrong some days I definitely feel this way too but more recently I have thought more about it both following training courses but also just generally in my day to day work.

The notes that we take serve a purpose. They let people know what is currently happening on the case. They record who has taken responsibility for particular tasks. It notes down the outcome of a meeting or assessment. It also covers our backs if something happens down the line. Good note taking makes sure that we can evidence exactly what was said or done in case it is needed.

One thing that was said to me on a training course recently was that the notes don't belong to us and I think when we look at them in the way I just described that is what they become. A record that we take for us when actually the record isn't ours. The person can ask at anytime to see what has been written there because it is about them. It makes us step back and be a bit more mindful when we think about it that way. We would not want someone we are supporting to see us describing the person closest to them as someone who interferes or takes over. We would not want them to read a note about themselves where we talk about them being “non-compliant” when actually they have a right to choose not to do something that they don't want to do. Negative comments or certain judgements being made on someone once can impact how people interact with them from that point onwards. One comment where someone is referred to as aggressive will potentially tar them with that brush and make finding placements etc difficult later down the line when it was actually they shouted at someone once cos they were upset. If I shout at someone or get frustrated nobody makes a note of it in my file. Just because someone has dementia or something similar does not mean they are not allowed to get angry or frustrated.

The records we keep show why we do what we do. Records of Capacity assessments and Best Interests decisions show how a conclusion was reached and expresses why it was the best thing for that person. It also means that if they or their family want to access that further down the line it is there for them to see. We take on a lot of responsibility when it comes to capacity assessments and best interest decisions but if we don't record them well then what is the point.

One tip that was given to me early on which I always make sure I do every time I complete a Capacity Assessment is to write exactly what the person said verbatim. What they say is not always relevant and sometimes makes no sense whatsoever but that shows that they were involved in the process. They may ask for something that is not an option such as living in their childhood home with parents who are no longer with us. Recording this shows that we have taken on board their wishes and allows us to record why that option was not actually an option at all.

We are there for them to support them and help them achieve their desired outcomes but record taking supports with this as it records their wishes and feelings as well as how we have done everything to have them involved.