How should I document my concerns regarding a child's safety and wellbeing in the medical record?

Document your concerns regarding a child's safety and wellbeing in the medical record by:

• Recording exactly what you have observed and heard, including who said what and when.
• Clearly stating why these observations or information cause concern.
• Noting whether you are considering, suspecting, or excluding child maltreatment as part of your clinical judgement.
• Documenting all actions taken, including discussions with colleagues or safeguarding professionals, referrals made, and the outcomes of these actions.
• Recording the reason for any decision to share or not share confidential information, what was shared, with whom, and for what purpose.
• Obtaining and documenting consent for sharing information where possible, ideally in writing; if consent is verbal, document this in the record.
• Ensuring that documentation is factual, clear, and avoids subjective or judgmental language.
• Maintaining confidentiality and considering the safety of the child and family when recording sensitive information.

These steps ensure a clear, comprehensive, and legally sound record that supports safeguarding actions and continuity of care.

References: NICE CKS, NICE CG89