Mosaic and Recording
Case recording should be purposeful, clear, relevant, objective, up-to-date and comprehensive. There should be a clear indication about what is fact and what is opinion. Case notes should be reflective of the adults and carer’s perspective and should not contain anything that could be construed as derogatory or misleading. Case recording should maintain a clear focus on the adults:
- Wellbeing
- Welfare
- Desired outcomes
Where information is not recorded, there is no evidence the work has been completed. If work was completed but not recorded well, it is considered unfit for purpose.