Legal actions can arise many years after an event’s occurrence. With the passage of time, you will likely forget the details. Since the court will use your records as evidence, the need for proper documentation becomes absolutely critical: If it is not recorded, it didn’t happen.
Very often, records can be the only means available to determine exactly the circumstances. You will need concise guidelines concerning the proper documentation; you cannot leave such documentation to chance. What, then, is “proper” documentation? Simply put, it is the written record that originated at the time and should include the following elements: Who was involved, what happened, and where did it happen?
Documentation “don’ts”: Never tamper with a record (including adding to an existing record at a later time), conceal information, rewrite the record, alter another person’s notes, and, do not describe a client/customer in negative terms).
1. Always document any comments that anyone makes about suing. These comments may be important evidence in a subsequent lawsuit.
2. Always follow through on something that was documented in the record. If your entry indicates that the parent will be taking their child to seek medical attention then make sure there is a follow up note indicating that it was done and the outcome.
3. Always document any information that you give to anyone. You must chart every substantive conversation between you and others. Lawsuits evolve from miscommunication. Only a documented conversation will hold up in court.
4. Always document any issues of noncompliance. If a parent is continually ignoring your requests and warnings, these and other instances need to be documented. This will show that you recognized the problems and addressed them.
5. Always document any injury to a child in your care. The record should be dated and also include entries on all the facts as known. Do not include apologies or conclusions as to why the event happened.
Please remember that your record is the only legal accounting of the circumstances and you must develop a method to make sure that the information you enter into your records is accurate and includes all information pertinent to the situation. Documentation is an integral part of your business function and needs to be viewed as a high priority. Without complete and accurate record keeping procedures, you stand a much higher chance of adverse judgments.