Record Keeping

Record keeping is the process by which an organisation manages all the aspects of records whether internally or externally generated and in any format or media type, from the creation all the way through the lifecycle to eventual disposal.

An organisations records are its corporate memory, providing evidence of actions and decisions. Records support policy formation and managerial decision making. Record keeping protects the interest of an organisation and the rights of their clients, members of the public and staff. They support consistency, continuity, efficiency and productivity and help deliver services in a consistent and equitable way.

All organisations should refer to their own professional/agency guidance on record keeping.

If an agency does not have their own Record Keeping Policy, they should ensure they work towards forming one, as implementing a Record Keeping Policy ensures an organisation’s commitment to ongoing improvement.

Key principles that underpin good record keeping are that they must be:

• Accurate – entries must be accurate, distinguish facts, opinions, assessments, judgments and decisions. They must distinguish firsthand information and information from third parties;
• Clear and chronological;
• Relevant;
• Timely (dated and signed by the professional making the record);
• Legible, easy to read and understand, with abbreviations explained in full.

Records must be:

• Available when needed - from which the Organisation can form a reconstruction of activities or events that have taken place;
• Accessible - records and the information within them can be located and displayed in a way consistent with its initial use, and that the current version is identified where multiple versions exist;
• Interpretable - the context of the record can be interpreted: who created or added to the record and when, during which business process, and how the record is related to other records;
• Trusted – the record reliably represents the information that was used in, or created by, the business process, and its integrity and authenticity can be demonstrated;
• Maintained through time – the qualities of availability, accessibility, interpretation and Organisation worthiness can be maintained for as long as the record is needed, perhaps permanently, despite changes of format;
• Secure - from unauthorised or inadvertent alteration or erasure, that access and disclosure are properly controlled, and audit trails will track all use and changes. To ensure that records are held in a robust format which remains readable for as long as records are required;
• Retained and disposed of appropriately - using consistent and documented retention and disposal procedures, which include provision for appraisal and the permanent preservation of records with archival value.

All staff must be aware of their responsibilities in record-keeping and record management.  Managers must be able to evidence training and record keeping standards measured through audit.

Standardised record keeping is essential so that agencies can demonstrate lawful decision making. Documentation in relation to a Safeguarding process can be significant in providing supporting evidence when making referrals to the Disclosure and Barring Service Barred List, care proceedings, criminal cases, the Royal Court, disciplinary hearings and complaints.

An organisations Records may be requested and must be made available to the court.

Records belonging to providers including providers of regulated services should be available to the commissioners of services and to the Public Health Department, and Jersey Care Commission. All records must be stored in accordance with your own agency’s policies with regard to the Data Protection (Jersey) Law 2018.

Service users may request access to their records where they are legally entitled to request a list of or a copy of any information that his held about them.

All agencies should identify arrangements, consistent with principles of fairness, for making records available to the subject and those with parental responsibility.

Each agency must keep comprehensive records demonstrating the work they have undertaken, which allow for continuity of care, assist with analysis, care planning, document outcomes and enable review and evaluation. Records provide a service user with a complete record of their care and in some circumstances for example children who are looked after documenting their childhood.

Staff are responsible for keeping timely, comprehensive records of good quality. Managers responsible for staff adhering to their record keeping policy.

Good Practice

Research in Practice (RIP) have published the Good Recording Practice Tool for professionals and managers which guides professionals through the standards of good record keeping. Agencies can access a free RIP account here.

Organisations must comply with the following legal and professional obligations:

• Children and Young People (Jersey) Law 2022 and the commensurate Statutory Guidance - should be read in conjunction with this chapter;
• United Nations Convention on the Rights of the Child (UNCRC);
• The Data Protection (Jersey) Law 2018;
• The Common Law Duty of Confidentiality;
• Caldicott Review 1997 (Health);
• Freedom of Information (Jersey) Law 2011.

Organisations should ensure they include in their policy any specific legislation relating to the profession of the organisation and ensure they include new legislation affecting records management where required.

Everyone who records, manages, stores, or otherwise comes across client information has a personal common law duty of confidentiality to the person and to his or her employer. The duty of confidence continues even after death of the person, or after an employee or contractor has left the Organisation. Services should have process to ensure all staff are advised regarding confidentiality on commencement of their employment and it is referred to in their job descriptions and contracts.

The implementation of the Data Protection (Jersey) Law 2018, which covers both computerised and manual personal data, establishes a set of principles with which users of personal information must comply. The Law imposes statutory restrictions on the use of personal information. For further information on the Data Protection Law, refer to the Data Protection Policy.

Sharing information is a key part of promoting the wellbeing, health and development of children and to safeguarding their welfare. The Children and Young People (Jersey) Law 2022 and commensurate Statutory Guidance sets out information sharing arrangements.

The lawful basis for sharing information related to the promotion and support of wellbeing is consent. At this level of need, the practitioner should ask the child and/or parents for consent to share information before making a submission to the Children and Families Hub.

The lawful basis for sharing information necessary to meet a health or development need or a safeguarding need is the performance of a public function.

The NHS Caldicott Committee recommends that NHS organisations and non-NHS organisations that deal with health information should be held accountable, through clinical governance procedures for continuously improving confidentiality and security procedures governing access to and storage of clinical information.

• All records or files must be stored in accordance with each agency's own policies and with regard to the Data Protection (Jersey) Law 2018;
• It may be inappropriate to document/store certain child protection information in the place normally used for service user records if, for example, you are working with a client at risk of domestic abuse, and the person alleged to have caused harm or associates may have access to that record;
• Advice should be sought from the Agency’s Safeguarding Lead in this instance and agency procedures for the storing of confidential information followed;
• Advice should be sought from that Agency’s Safeguarding Lead or their line manager if the Safeguarding Lead is conflicted;
• Each agency should ensure there is a protocol in place detailing the length of time for which records are to be held in line with requirements.

Children and Young People (Jersey) Law 2022 and commensurate Statutory Guidance

United Nations Convention on the Rights of the Child (UNCRC)

The Data Protection (Jersey) Law 2018

Caldicott Review 1997 (Health)

Freedom of Information (Jersey) Law 2011