9. Record keeping
9. Record Keeping
- 9.1. Records must always be made with great care. They will almost always be open to inspection by others, including those about whom they are made; they may be required as evidence in case reviews of legal proceedings.
- 9.2. Good records are factual, accurate, legible, comprehensive and made as soon after the incident as possible. They include direct evidence, such as the words used by individuals themselves, and specific information, such as the exact location of an injury (e.g., bruising 'on the left lower forearm just above the wrist', rather than 'on the arm'). Diagrams which explain family relationships, layouts of locations, or locations of injuries are helpful.
When making records, do not:
- make value judgements about those involved
- criticise those involved for their behaviours, attitudes, beliefs or actions
- use jargon, slang, derogatory or negative language about victims or perpetrators
- use abbreviations which are not explained
- speculate or make assumptions about someone's explanations or actions. Speculating makes assumptions; professional curiosity teases out concerns and prevents assumptions being made
- Always record:
- the date and time of the incident
- the person's name, address and date of birth
- the nature of the allegation or incident and, if possible, the name, address, date of birth or any others involved, including the employer of anyone alleged to have caused the harm
- factual observations: visible injuries, the person's behaviour / physical / emotional state, etc.
- exactly what they said, using their own words, and exactly what you said
- their consent to share the information
- all actions you took: who you spoke to and all resulting actions so far. Include names, addresses and telephone numbers wherever possible
- complete the Safeguarding Report Form available on the Council's website and/or intranet (The Loop) which will then be stored on Great Yarmouth borough Council's secure case management (E-CINS)
- consider whether the person needs adding to the Council's 'Warning Marker' system. If you feel that staff, councillors, volunteers, contractors or consultants may be at risk of harm from the person, seek advice from the Health and Safety Officer
- 9.3. For every safeguarding incident report by an officer, the officer is expected to discuss the issue, and all action taken, with the Designated Safeguarding Officer for your service and complete the Safeguarding Report Form available on the Council's intranet site (The Loop).
- 9.4. Staff without IT access should telephone the Designated Safeguarding Officer for their service.