What you should record

1. 52. You must keep clear, accurate and legible records. You must record your concerns, including minor ones, in the child’s or young person’s records (and in their parents’ records if you have access to them). You must also record clinical findings, decisions you have made, actions you have taken, information you have given and received, and conversations you have had with the child, young person, their parents or other family members. You must make the records at the time that the events you are recording happen, or as soon as possible afterwards.
2. 53. If you share information, you must record this in the child’s or young person’s records. If you share information about members of the child’s or young person’s family, you should include this in their records if you have access to them. You should include details of the information you shared, who you shared it with and why. You should also include whether consent was given and, if so, who gave it.
3. 54. If you share confidential information without consent, you must record the reasons for your decision. You should also record any steps you took to try to get consent or your reasons for not doing so, and details of any advice you received.
4. 55. If, after getting advice, you decide not to share information, you must be prepared to justify that decision. You must record your decision and your reasons for not sharing information.
5. 56. Medical records are made to support safe and effective care but they may be used for other purposes. For example, they may be used when making decisions about a child’s or young person’s safety or welfare, as they can help build up a picture over time. They may also be used as evidence in court. It is particularly important that records relating to the possible abuse or neglect of a child or young person are full, accurate, dated and timed, and distinguish between clinical findings, your opinions and information provided by others. You should clearly record any continuing uncertainty about the risk of abuse or neglect to a child or young person because this information may be relevant if put together with other information about the child or young person or their family.
6. 57. If there is not enough evidence to support your concerns that a child or young person is being abused or neglected, or the evidence shows that your concerns are not correct, you should record this clearly in the child’s or young person’s medical record and in their parents’ records. You should explain to the child or young person and their parents why information about these events will remain on their medical records.