Induction Standards for Northern Ireland

Standard 4: Communicate effectively: The principles of good record-keeping

Good record-keeping is an essential part of social care work. Carers need to communicate with each other on a daily basis. They need to let each other know what has happened on their shift. When the shifts change, some teams have handover meetings in order to discuss the day’s events. Others use communications books or daily logs to communicate between shifts. Useful entries give lots of information. Records are kept to ensure good and consistent care and to help staff work together. Records can be used to evidence that tasks have been completed or let other staff know about service users’ experiences, needs or events.

You need to know how to record information appropriately. Records are official documents and contain important information. They may be read by different people, including other staff and inspectors. You need to ensure that what is written is legible, accurate and respectful of anybody referred to. 

Look at the following resources:

Check your understanding

  • How does your record-keeping benefit the people you care for?
  • What communication skills do you need for record-keeping?
  • How could you improve your record-keeping skills?
  • Are you confident in your own ability to communicate clearly, both when speaking and writing? If not, ask your supervisor for ideas to help you improve.

Did you know?

  • Poor communication is very often the reason why things go wrong in care situations.

Record what you have learned

  • Your organisation may have a Learning Record Form. If so, use that to write down what you have learned and any questions you might have. Otherwise you can use our Learning Record Form.