1.7 Explain how to complete records of the actions taken and the individual’s condition during the healthcare activity

This guide will help you answer 1.7 Explain how to complete records of the actions taken and the individual’s condition during the healthcare activity.

Recording information about actions taken and an individual’s condition is a standard part of any healthcare role. Accurate records show what you did, when, and why. This protects the individual receiving care, supports good practice, and shows compliance with regulations.

Records serve several purposes:

They provide a factual account of the care delivered.
They help monitor changes in an individual’s condition.
They support communication between care workers and other professionals.
They create legal evidence of the care provided.
They support informed decision making for ongoing care.

Keeping clear and accurate records safeguards both individuals and staff. It helps avoid misunderstandings, mistakes, and potential complaints.

Types of Records Used

Many forms are used during healthcare activities. You might complete daily records, incident forms, medication charts, fluid balance sheets, or wound care records.

Each type of record collects specific information, but all share basic principles:

They must be clear and legible.
They must be completed as soon as possible after the care activity.
They must only include factual, objective information.

Subjective opinions should be avoided. If it is necessary to give an opinion, it needs to be clearly identified as such and based on sound evidence.

Legal and Regulatory Duties

Recording information correctly is a legal requirement. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, for England, outlines responsibilities for accurate record keeping.

The General Data Protection Regulation (GDPR) and the Data Protection Act 2018 protect the security and confidentiality of information.

Poor or incomplete documentation can have serious consequences:

Risks to the individual’s health or safety can be missed.
Investigations into allegations or incidents may be hindered.
Staff and organisations can face disciplinary action, prosecution, or loss of registration.

Everyone involved in providing care has a duty to complete records properly.

What Information to Record

When completing records about actions taken and the individual’s condition, include the following:

Name of the individual
Date and time of the care activity
Description of the care activity undertaken
Any support provided or assistance given
The outcome or response of the individual
Details of any changes from previous observations
Any communication with colleagues, family, or other professionals
Sign and print your name and add your job title

Record both routine and unexpected events. For example, if you assist with personal care, note how the person responded and their general condition. If you give medication, document the time, dose, and any effect.

Specific guidance may apply for some tasks, such as wound dressing or monitoring blood pressure. Always check local policies.

How to Record Information

Follow these key points when writing records:

Be Clear and Accurate

Write factually. Use straightforward language. Avoid jargon unless it is standard practice and understood by everyone reading the record. If using abbreviations, only use those approved by your organisation.

Write Legibly

Where records are hand-written, print clearly. Unclear handwriting can cause mistakes.

Use Correct Dates and Times

Document events in real time or as soon as you finish the activity. Always use the 24-hour clock where required and be consistent.

Record Facts, Not Opinions

Document what you observe and do. If you need to record an opinion, explain what it is based on. For example:
“The individual appeared drowsy and slept for much of the morning. Their speech was slurred (observation). I think they may be more tired due to their medication being changed yesterday (opinion, with reason).”

Maintain Confidentiality

Only include relevant information. Do not record unnecessary or irrelevant personal details.

Correct Errors Properly

If you make an error, draw a single line through the incorrect entry, write the word ‘error’, and sign and date the correction. Never use correction fluid or erase entries.

Sign and Date Every Entry

Always sign your full name. Write the date and time of the entry. This shows who did what and when.

Store Records Securely

Paper records should be kept in locked cabinets or storage areas. Electronic records should be password-protected.

Electronic and Paper Record Systems

Many health and social care settings use a combination of paper and electronic records.

If using electronic records:

Log out when finished to prevent unauthorised access.
Follow security protocols for passwords and access rights.
Double-check information before saving or submitting entries.

If using paper records:

Make sure sheets or charts cannot be altered afterwards.
Keep files in secure places when not in use.
Do not leave records unattended in areas accessible to the public.

Recording Observations

Observations about the individual’s condition should be detailed and specific.

Physical Observations:

General appearance (e.g., pale, flushed, sweating)
Breathing (e.g., shortness of breath, coughing)
Movement (e.g., walking steadily, needed support)
Skin integrity (e.g., sores or wounds)
Food and fluid intake/output

Emotional and Mental Wellbeing:

Mood (e.g., cheerful, withdrawn, anxious)
Communication (e.g., talking, quiet, agitated)
Behaviour (e.g., co-operative, distressed, aggressive)

Whenever possible, use measurable data:

Temperature, blood pressure, pulse, or other health checks
Weight or body mass (BMI)
Volume of fluids consumed or output (for catheter or continence care)

If you observe a change from the individual’s usual patterns, record what you notice in detail and inform the appropriate person.

Recording Actions Taken

Details about what you did should include:

What exactly was done (e.g., assisted with bathing, gave pain relief)
Who was involved (e.g., yourself, colleague, district nurse)
Equipment or techniques used (e.g., hoist, walking frame)
How the individual responded (e.g., co-operative, uncomfortable)

Be precise. Do not use vague descriptions such as “looked after” or “given care”. Spell out what you actually did.

Example:

“At 09:00, assisted Mr Smith with transferring from bed to wheelchair using a standing hoist. Mr Smith required moderate support and followed instructions. No skin tears or discomfort noted. Transfer completed safely. Signed: Jane Brown, Care Assistant.”

Communication and Reporting

If you discuss the individual’s care or condition with another member of staff, a relative, or a visiting professional, make a note of the:

Date and time
Name and role of the person you communicated with
Nature and outcome of the conversation

If you pass on information, document what was said and what action was agreed.

This helps create a clear record and avoids confusion if there are any later disagreements.

Following Organisational Procedures

Every health and social care organisation has policies about record keeping. You must follow these at all times.

Check:

The required format (e.g., specific forms, charts, or digital systems)
The approved abbreviations
Who to report to if you notice something unusual or there is an incident

If you are unsure, ask your supervisor.

Using Person-Centred Language

Respect the dignity of individuals by using language that is inclusive, respectful and positive.

Do not use words or phrases that could be considered disrespectful or discriminatory. Avoid making assumptions about a person’s feelings or experiences.

Record what you see and do in a sensitive, factual way.

Examples:

“Supported Ms Patel to eat breakfast. She chose scrambled eggs and a cup of tea.”
“Noticed new bruise on Mr Gray’s right arm. Informed nurse and completed accident report.”

Timeliness of Recording

Record information as soon as possible after the activity. Delays increase the risk of forgetting important details or making mistakes.

If circumstances force you to record later, make it clear in your entry and explain why.

Example:

“Recorded at 11:30 – care activity was completed at 10:15, delay due to emergency with another service user.”

Confidentiality and Information Sharing

Keep in mind who will read the record. Information is usually shared with relevant colleagues but should not be shared with others outside the care team without proper consent.

Bear in mind:

Records must respect privacy
Personal data must only be shared when legally permitted

Only document information that is necessary and relevant to the individual’s care.

Record Keeping in Special Circumstances

There are times when extra care in record keeping is required:

Safeguarding Concerns

If you suspect or observe abuse or neglect, record what you see or hear in as much detail as possible. Avoid stating opinions or making accusations.

Your record might be used as evidence in a formal investigation. Be specific about who said or did what, where, and when.

Accidents or Incidents

Complete accident or incident forms in line with organisational policy. Include:

Exact location, date, and time
Who was involved
Sequence of events
Any injuries or harm
Actions taken and by whom

Medicine Administration

Record the medicine given, the dose, time, method (e.g., tablet, liquid), and any reaction. If a dose is omitted or refused, state the reason.

Reviewing and Auditing Records

Records are often checked or audited by managers or external inspectors. Auditing checks the quality and accuracy of records, identifies gaps or errors, and helps improve care.

Good record keeping:

Reflects positively during inspections
Demonstrates safe working practices
Supports learning and improvement

Poor records signal neglect, lack of training, or unsafe care.

Training and Development

Good record keeping is a skill. Staff are often trained in how to complete records and keep information secure. Training covers:

Legal duties
Organisational policies
Using digital systems
Recognising and reporting concerns

Always seek support or training if you feel unsure about how to complete records correctly.

Final Thoughts

Completing records for actions taken and the individual’s condition during healthcare activity is a major responsibility.

Remember to record facts, not opinions. Keep your entries timely, accurate, concise, and respectful. Use clear handwriting or approved electronic systems. Correct errors without hiding them.

Follow your workplace guidance at all times. If in doubt, speak to your manager.

Effective record keeping is a foundation for safe care and a key part of every health and social care worker’s role.