Safeguarding is everyone's responsibility, and care records play a critical role in identifying, escalating, and evidencing concerns. But certain language patterns in notes can indicate that safeguarding issues are being documented without being properly recognised or acted upon.
Red Flag Phrases
Watch for these patterns in your team's documentation:
"Resident was found on the floor"
This phrase appears frequently in care notes but often lacks context. Was the fall witnessed? Was there an injury? Was the GP notified? Were the falls risk assessment and care plan updated?
"Bruise noted" without explanation
Unexplained marks should always trigger a body map and investigation. Simply noting a bruise without follow-up documentation is a safeguarding gap.
"Resident was agitated / aggressive"
Labelling behaviour without exploring the cause can mask pain, distress, or abuse. Notes should describe what happened, explore potential triggers, and document the response.
"Told not to report" or "family requested no action"
Safeguarding cannot be overridden by family or staff requests. Any such statements in records should be immediately escalated.
"Same as yesterday" or "no change"
Repeated identical entries may mask deterioration or neglect. Each entry should be unique and reflect genuine observation.
Building a Safeguarding Culture
Training staff to recognise these patterns in their own writing is one of the most powerful safeguarding interventions available. Regular documentation audits and peer reviews can help identify gaps before they become serious concerns.
Disclaimer: This article is for informational purposes only. Evidentia provides AI-assisted suggestions and does not constitute safeguarding, legal, or regulatory advice. Always follow your organisation's safeguarding procedures.
Evidentia Team
Compliance intelligence insights from the Recordsafe team.