NA50-Documentation and Care Records Policy
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{{org_field_name}}
Registration Number: {{org_field_registration_no}}
Documentation and Care Records Policy
1. Purpose
The purpose of this policy is to establish clear, legally compliant, and best practice standards for documentation and care records management within {{org_field_name}}. Accurate, timely, and complete record-keeping is essential for the delivery of safe, high-quality, and person-centred care. Documentation provides evidence of care provided, supports effective communication between healthcare professionals, promotes continuity of care, and protects the legal and professional integrity of both the organisation and its staff. This policy is designed to ensure that all temporary workers, including registered nurses and healthcare assistants supplied by {{org_field_name}}, understand their responsibilities in relation to documentation and care records in the settings where they are deployed. This policy is aligned with the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, the Data Protection Act 2018 and UK GDPR, the Nursing and Midwifery Council (NMC) Code, the Care Quality Commission (CQC) Fundamental Standards, the Mental Capacity Act 2005, and other applicable guidance. It reflects current best practice and will be reviewed annually to ensure ongoing compliance and effectiveness.
2. Scope
This policy applies to: All temporary workers supplied by {{org_field_name}}, including registered nurses, healthcare assistants, and any other temporary staff providing care. All records created, completed, or maintained by agency staff during their placement, including service user care records, observation charts, incident forms, medication records, communication logs, and electronic records where applicable. All settings where {{org_field_name}} staff are deployed, including care homes, nursing homes, and other health and social care establishments. This policy applies equally to handwritten and electronic records.
3. Related Policies
- Confidentiality and Data Protection Policy – Safeguarding Adults Policy – Consent, Mental Capacity and Best Interests Policy – Incident Reporting Policy – End of Life and Advance Care Planning Policy – Whistleblowing Policy – Training and Development Policy
4. Policy Statement
{{org_field_name}} is committed to ensuring that all records produced and maintained by its staff are: Accurate and factual. Timely and contemporaneous. Complete and comprehensive. Legible and written in plain English. Confidential and compliant with data protection legislation. Clear, respectful, and free from discriminatory, offensive, or judgemental language. Documentation will be regarded as a vital part of the delivery of care and will form part of clinical governance and quality assurance.
5. Responsibilities
Directors In the absence of a registered manager, the directors of {{org_field_name}} will: Ensure that all staff receive mandatory training on documentation and record-keeping principles during induction and as part of refresher training. Monitor compliance through audits, client feedback, and incident reviews. Provide guidance and support to staff regarding documentation and record-keeping. Review and update this policy as required. Investigate incidents of poor documentation and take appropriate action.
Temporary Staff All temporary workers engaged by {{org_field_name}} must: Record care accurately, objectively, and legibly in line with this policy and the client’s documentation systems. Complete documentation in a timely manner and never delay recording important information. Follow any placement-specific documentation procedures, including electronic systems, paper records, or combined methods. Communicate information clearly to other members of the care team. Seek guidance from the placement manager or the agency if they are unsure how to complete records.
6. Legal and Regulatory Requirements
All documentation produced by {{org_field_name}} staff must comply with the following legislation and guidance: Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (Regulation 17 – Good Governance). Data Protection Act 2018 and UK GDPR. NMC Code of Conduct (for registered nurses). Care Certificate Standards (for unregistered care workers). CQC Fundamental Standards. Mental Capacity Act 2005 and related Codes of Practice.
7. Principles of Good Record Keeping
Staff must adhere to the following principles when completing documentation: Records must be: Accurate: Facts must be recorded truthfully and verified. Clear: Avoid ambiguity, jargon, or abbreviations unless they are widely accepted. Legible: Handwritten records must be readable and written in black ink. Contemporaneous: Record information as soon as possible after the event or intervention. Signed and dated: All entries must include the staff member’s full name, signature, and designation. Confidential: Only shared on a need-to-know basis in accordance with data protection legislation. Respectful: Avoid subjective or judgemental comments. Records must never be altered, falsified, or backdated.
8. Content of Care Records
Staff must record: All care provided, including personal care, nutritional support, repositioning, or social engagement. Clinical observations (e.g., blood pressure, temperature, pulse, blood glucose) as required by the care plan. Medication administration where authorised and trained to do so. The individual’s response to care. Changes in condition, behaviour, or emotional wellbeing. Discussions with family members or advocates where relevant. Safeguarding concerns, incidents, or accidents following local reporting protocols. Actions taken and who was informed.
9. Electronic Record Keeping
Where electronic records are used: Staff must follow the client’s protocols for logging, entering, and securing information. Passwords and access credentials must never be shared. Only agency staff who have received training on the system may use it. Electronic records must comply fully with the same legal, professional, and ethical standards as paper records.
10. Confidentiality
All records are confidential and must be handled in accordance with {{org_field_name}}’s Confidentiality and Data Protection Policy. Staff must: Only access records required to carry out their role. Share information only with authorised individuals on a need-to-know basis. Store completed documentation securely at the placement site. Never remove service user records from the care setting. Report any data breaches immediately to the client and to {{org_field_name}}.
11. Record Keeping in Relation to Mental Capacity
When working with individuals who may lack capacity, staff must: Document capacity assessments and decision-making processes. Record involvement of family members, advocates, or Independent Mental Capacity Advocates (IMCAs). Clearly record best interest decisions. Comply with the Mental Capacity Act 2005 and related Codes of Practice.
12. Incident Reporting
Staff must: Complete incident forms promptly and accurately following any accident, near-miss, safeguarding concern, or other incident. Follow both the placement’s and {{org_field_name}}’s incident reporting procedures. Record incidents factually, clearly, and without assigning blame.
13. Consent
Staff must ensure: Consent is sought for all care and treatment where the individual has capacity. Documentation reflects when consent is given or declined. Where consent is not possible, actions are documented following the Mental Capacity Act 2005 principles.
14. Accountability and Professional Responsibility
All agency workers are personally responsible for the records they complete. For registered nurses, record keeping is an explicit requirement of the NMC Code. Poor documentation may result in disciplinary action, referral to professional bodies, and may compromise service user safety.
15. Auditing and Monitoring
{{org_field_name}} directors will: Audit documentation practices through client feedback and internal reviews. Investigate any concerns about poor documentation. Take corrective action where needed, including further training or disciplinary processes. Use audit outcomes to inform quality improvement initiatives.
16. Training
All staff will receive training on: Principles of good record keeping. Documentation in the context of safeguarding, consent, and the Mental Capacity Act. Legal and professional obligations relating to care records. Confidentiality and data protection principles. Refresher training will be provided annually or as necessary.
17. Supervision and Support
{{org_field_name}} will: Provide staff with supervision and guidance where documentation concerns are identified. Offer additional support or retraining if staff experience difficulty meeting documentation requirements. Ensure that directors are available to respond to queries about documentation at any time.
18. Continuous Improvement
{{org_field_name}} will: Regularly review documentation practices across placements. Update this policy in response to legislation, regulatory requirements, and best practice developments. Seek feedback from clients and staff regarding documentation quality and usefulness. Integrate lessons learned from incidents, complaints, and audits into practice improvements.
19. Policy Review
This policy will be reviewed annually or earlier if: There are changes in legislation or national guidance. Feedback or audits indicate a need for revision. New documentation systems or processes are introduced by client organisations.
Responsible Person: {{org_field_registered_manager_first_name}} {{org_field_registered_manager_last_name}}
Reviewed on: {{last_update_date}}
Next Review Date: {{next_review_date}}
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