Keep accurate records — guidance

I will know I've achieved this standard when...

I have clearly demonstrated my implementation of the practice standards for each tamaiti I work with in my case notes, assessments, plans and reports

• Your every-day case notes, assessments, plans and reports all provide a picture of how you are using, meeting and practicing at least the minimum requirements within the Oranga Tamariki Practice Standards.
• As you undertake your day-to-day work (engaging, assessing and making decisions for te tamaiti at various points in their journey), you record this process and the reasons for your decisions. This acts as documented evidence of your practice.
• Remember that anything you record about te tamaiti needs to be clear and easily understood. You are recording a story of their journey to oranga, and what you document about them and the people close to them is there for life. The best interests of te tamaiti should inform how records are made and kept.
• If tamariki want to access their information, ensure they can understand the information being released and they have adequate support at that time. What you say must be transparent, neutral and non-judgemental. Consider what te tamaiti might think if, when they are older, they read what you have documented about them and the people in their life. Is it fair? Is it accurate? Is it written in a way that they can make sense of?
• Personal information must be kept safe and secure, shared only for the purpose of delivering better services to tamariki and whānau. All of the information needs to adhere to requirements within the Privacy Act 2020. At the same time, everything you document is ‘discoverable’ as part of our obligations under the Official Information Act.

I have clearly documented any key decisions I have made or actions I have taken for each tamaiti I work with, who was involved, the rationale for those decisions or actions and my next steps

• Your records show your analysis of information, your actions and the decisions you make for each tamaiti you work with. It is important in this process to differentiate fact from opinion. When you record this information, you create a transparency about your practice approach and the advice you have received and provided.
• Records about your decisions for te tamaiti also inform discussions with your supervisor and colleagues. Any decisions made as a result of these discussions should be documented in your records, with the rationale and other relevant details included.
• Your records also identify the key people you have engaged with in the work you have been doing for each tamaiti. Seeing and engaging tamariki, whānau, caregivers and, where relevant, victims of offending by tamariki, is a minimum requirement for your practice. Your records need to document your process in doing this for each tamaiti you work with.
• You need to document the views and perspectives of tamariki, whānau, caregivers and the victims of offending by tamariki. You need to record how this information has informed your decision-making. This will in turn inform your conversations with te tamaiti as you discuss the next steps with them.
• Some key areas to include in your documentation are:
  • who you engaged with, when and how (e.g. face to face, email, letter, phone call, text)
  • how you enabled participation in decisions for te tamaiti, whānau, caregivers, the victims of offending by tamariki and other relevant people
  • what views and perspectives were shared with you by te tamaiti, whānau, caregivers and victims of offending by tamariki
  • what relevant information was provided by other key people involved with te tamaiti
  • information on any possible trauma history for te tamaiti (including disrupted attachment, hospitalisations, signs of abuse and neglect) and any possible trauma history for whānau and caregivers
  • your decisions, actions and rationale; this is particularly important in order to record case progress and any changes in the direction of the case
  • how you considered the views of te tamaiti, whānau, caregivers, the victims of offending by tamariki and all other key people supporting te tamaiti
  • how supervision helped inform your decisions and actions
  • how and when you have communicated your decisions, actions, plans and next steps with te tamaiti, whānau, caregivers and the victims of offending by tamariki.
• Where possible, develop a chronology or timeline of critical key events and changes for te tamaiti that have occurred for them and their whānau across their lifespan. This enables you to look across time and see what has happened for te tamaiti. It helps you decide how best to respond to their needs in order to minimise on-going harm, loss of attachments and trauma.

I have clearly documented how tamaiti, their whānau, caregivers or others working with them have responded to my decisions

• When you communicate about decisions with te tamaiti, their whānau, caregivers, victims and other key professionals, you need to decide to what type of communication works best for them.
• There are a variety of ways and particular times where it is important to share information. Examples include at hui-a- whānau, meetings, in writing via letters or reports, via text, e-mail or in face to face visits.
• Take note in your records how te tamaiti, whānau, caregivers, victims and other key professionals respond to the decisions made. Ensure tamariki know that their views on your decisions have been taken into account and recorded, along with your reasons for the decisions.

I have clearly documented any oversight/approval that has been obtained for key decisions that require it

• Record discussions, key points and decisions made during supervision or case consults, including your next steps. Review records often to keep them current and accurate.
• Within Oranga Tamariki, key decisions must be made in collaboration with a supervisor.