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Reporting & Recording
Accurate, timely recording is critical to safe care. What you observe, report, and record can be the difference between a concern being caught early and a serious incident being missed.
Why Recording Matters
Every record you make becomes part of the client's care history. It informs clinical decisions, supports continuity between carers, provides evidence for regulatory inspections, and can be used in legal proceedings. Your records must be factual, accurate, timely, and complete.
What to Observe on Every Visit
Three Questions to Ask Yourself
Is the client telling me
verbally or non-verbally — that they feel unwell or in pain?
Does what I am seeing suggest the client may need a clinical assessment?
Has something prevented me from delivering the planned care as documented in the Support Plan?
When to Escalate
Emergency situation (client unresponsive, severe injury, chest pain, stroke symptoms) — call 999 immediately, then contact your manager
Any change in the client's condition — call your manager immediately by phone
Client declines care or a specific task — record the refusal and inform your manager by phone
Unable to gain access to the client's home — contact your manager immediately
Equipment fault or missing equipment — do not improvise, contact your manager
Recording Standards
Safeguarding Concerns — Special Reporting Rule
If you have a safeguarding concern — including suspected abuse, neglect, or exploitation — report it to your manager by phone immediately. Do NOT record safeguarding concerns in the care notes app unless specifically instructed to do so by your manager. Safeguarding reports follow a separate, confidential process.