Care recordkeeping guidance for providers

Guidance for providers on creating, managing and providing access to care records.

About care records

Care records are the pieces of information that an organisation creates or records about a person while responsible for providing them with care or support.

Care records are taonga for the person the records are about. They can hold memories, connections, and explain important decisions that were made about the person. When created, looked after, and provided in a person-centred way, these records can provide meaningful answers for questions in people’s lives.

What DSS care recordkeeping guidance covers

This guidance and supporting resources focus on the key practice areas of creating, managing and providing access to care records.

Their purpose is to help disability support service providers to better understand their care recordkeeping obligations and improve their practices.

These resources have been developed with the support of our provider reference group and include: 

  • detailed guidance on creating, managing and providing access to records (broken down into legal obligations and practice improvement opportunities for each practice area)
  • a plain language summary of the guidance (also available in alternate formats)  
  • quick reference guides for frontline staff responsible for creating, managing and providing access to care records
  • a glossary of key terms used throughout the material  
  • exemplar documents and templates to demonstrate good records creation
  • links to other useful resources for DSS providers. 

In response to what providers told us, we have ensured this guidance:

  • includes guidelines about care records management obligations 
  • includes practical and concrete examples of what good records look like
  • has been built alongside and tested with providers from the start.

Links to the guidance

Below are the links to quick reference guides by subject, as well as the full guidance: 

Here are plain language summaries of the recordkeeping guidance in alternate formats:

How the guidance was developed

The Royal Commission of Inquiry into Abuse in Care identified issues and inconsistencies with recordkeeping practices across the range of organisations that create, manage and provide access to people’s care records.  

Archives NZ is leading work to design overarching recordkeeping guidance for the public sector and is developing national standards and guidance on best practice record keeping based on the Care Records Framework external

While they are working on this broader guidance, we have worked alongside Archives NZ to develop interim best practice guidance specific to the disability sector to support our providers better understand and meet their record keeping obligations.

We worked with People First to test the direction of the work with the disabled community and to ensure that the practices described in the guidance would improve outcomes for disabled people.

A Provider Reference Group has provided feedback and support in the building and testing of this guidance, ensuring it is effective and fit for purpose.

Recordkeeping support

If you have recordkeeping questions that your organisation’s internal experts aren’t able to answer, you can send these questions through to DSS and MSD’s Privacy team at privacyofficer@msd.govt.nz.