What is Record Keeping in Health and Social Care?

Record keeping in health and social care means collecting, storing, and managing written or digital information about the care and support provided to a person. It involves keeping accurate, clear, and up-to-date details about a service user’s needs, treatments, progress, and changes over time. These records give a clear picture of the care given and help staff work safely and effectively. Good record keeping protects both the person receiving care and the staff providing it.

In health and social care, records can be paper-based, stored in files or folders, or kept electronically. Either way, they must be readable, factual, and securely stored. The information’s purpose is to support communication between professionals, meet legal requirements, and guide future care decisions.

What is the Purpose of Record Keeping?

The main purpose of record keeping is to make sure everyone involved in a person’s care has access to accurate information. Good records help staff understand the person’s needs, history, and preferences, making care safer and more personalised.

It gives a clear picture of what has been done, what needs to be done, and what goals have been set. It also shows whether agreed care plans are working.

Some purposes include:

• Supporting communication between health and social care staff
• Meeting legal and professional standards
• Providing evidence of services delivered
• Monitoring a person’s progress or changes in health
• Supporting investigations if mistakes or incidents happen
• Helping plan ongoing or future care

Without proper records, communication breaks down, and the risk of mistakes increases.

What are the Types of Records?

Health and social care providers keep several different types of records. Each type contains different information and serves a different purpose. Examples include:

• Care plans – These outline a person’s needs, preferences, and support arrangements. They are updated regularly to reflect any changes.
• Risk assessments – These identify potential risks to safety and detail steps to reduce them.
• Daily notes – Staff record what happened during a shift, such as meals eaten, medication given, or mood changes.
• Medical records – These contain medical history, diagnoses, treatments, and test results.
• Medication administration records (MARs) – These track when medication was given, the dosage, and any issues.
• Incident reports – These document accidents, injuries, or problems that occurred during care.

Each type supports different decisions and ensures clear communication across care providers.

Legal and Regulatory Requirements

In the UK, record keeping in health and social care is shaped by laws, regulations, and professional standards. These aim to protect people’s privacy and ensure they receive safe, high-quality care.

The Data Protection Act 2018 and the UK General Data Protection Regulation (GDPR) outline how personal information must be collected, used, and stored. They require data to be accurate, kept up-to-date, and stored securely.

The Care Quality Commission (CQC) in England inspects and monitors care services. They expect records to be accurate, complete, and available when needed.

Professional bodies such as the Nursing and Midwifery Council (NMC) and the Health and Care Professions Council (HCPC) also have record keeping standards for their members. These guide how records are written, stored, and shared to protect people and maintain trust.

Characteristics of Good Record Keeping

Good record keeping has certain qualities that make it reliable and useful. Records should be:

• Accurate – Record facts, not personal opinions, unless clearly labelled as observations.
• Clear – Write in plain, simple language so others can understand.
• Complete – Include all relevant details without missing important points.
• Up-to-date – Add information as soon as possible after events occur.
• Legible – Handwritten records must be easy to read; electronic records must be free from errors.
• Secure – Keep physical files locked away and protect digital files with passwords.

These traits help prevent confusion and mistakes, and they maintain a record’s value as evidence.

How Records Support Communication in Care

Records are one of the main ways that information is shared between professionals. In health and social care, many people can be involved in a person’s care, such as nurses, doctors, social workers, and carers.

Without accurate records, staff might not know about updates to the care plan, changes in medication, or important incidents. Clear written or electronic records mean that anyone providing care can quickly see what is happening and what has changed.

For example, if a care worker notices a service user is feeling unwell, they can record the symptoms and any actions taken. Another staff member reading the notes later can continue care with full knowledge of what has already been done.

Maintaining Confidentiality

Confidentiality means keeping personal information private and sharing it only with people who need it to provide care.

This protects trust between the service user and the care provider. It is also a legal requirement in the UK. Professional guidelines require staff to keep all records secure and prevent unauthorised access.

Steps to protect confidentiality include:

• Locking paper records in secure cabinets
• Using password protection and data encryption for digital files
• Storing only the information needed for providing safe care
• Sharing records only with authorised professionals

Breaches of confidentiality can lead to legal penalties and damage to trust in care services.

Paper vs Digital Records

Care providers may keep records on paper or in digital format. Each has its benefits and drawbacks.

Paper records are straightforward, do not need technology, and can be written easily during care. They can be used during power cuts or technical failures. However, they take up space and can be lost or damaged.

Digital records save storage space, can be backed up, and allow quick sharing between professionals in different locations. They can include alerts or reminders about medication or appointments. But they depend on technology and require training to use.

Many organisations use a mix of both, depending on the setting and their resources.

Accuracy and Accountability

Record keeping is linked to accountability. Every entry shows what actions were taken, when, and by whom. Staff usually date and sign or log every record so it is clear who provided the information.

If things go wrong, accurate records can help explain decisions and actions taken. They provide a timeline of care, which can be used in investigations or legal processes.

If records are poor or missing, it becomes harder to defend actions, improve practices, or learn from mistakes.

Common Challenges in Record Keeping

Staff in health and social care often face challenges in keeping records. These can include:

• Time pressures during busy shifts
• Lack of training in writing clear and factual notes
• Technical problems with electronic systems
• Misplacement or damage of paper records
• Unclear policies or inconsistent procedures

Overcoming these issues requires good training, clear organisational policies, and enough time allocated for staff to complete records properly.

The Role of Training

Training helps staff learn how to create records that meet professional and legal standards. It covers topics such as:

• Writing factually and avoiding unhelpful personal language
• Knowing what details to include and what to leave out
• Understanding confidentiality and data protection laws
• Using electronic systems correctly

Good training helps staff understand that records are not just paperwork but a vital part of care.

Record Storage and Retention

In the UK, records must be kept for certain periods before being destroyed. This is called a retention schedule.

For example, adult medical records in NHS services are usually kept for eight years after the last treatment, while records for children are kept until the child is 25 years old or eight years after death.

When the retention period ends, records should be destroyed securely to maintain confidentiality, such as by shredding paper files or permanently deleting digital data.

The Role of Service Users

Sometimes, service users are involved in checking or adding to their own records. For example, they might see their care plan, add their preferences, or sign agreements.

This can help them feel more in control of their own care and ensure that their needs and wishes are correctly recorded.

Final Thoughts

Record keeping in health and social care is more than just writing down information. It is about creating reliable, safe, and clear records that guide care, support communication between staff, and meet legal and professional requirements.

Good records protect everyone—service users receive better care, and staff have the information they need to work safely. Poor records can lead to mistakes, misunderstandings, and risks to health and wellbeing.

By keeping records accurate, clear, secure, and current, organisations can make sure that care is consistent, well-organised, and respectful of people’s rights. This is why record keeping remains one of the most important responsibilities for anyone working in health and social care.