Information Sharing and Recording

Effective safeguarding depends on timely, accurate information reaching the right people. ^[1] Data protection law enables sharing to prevent or detect serious harm, provided disclosures are necessary, proportionate, and documented. ^[2][5] Records should allow others to reconstruct events, decisions, and rationales without ambiguity. ^[4]

Sharing lawfully and proportionately

• Lawful basis: public task or essential interests typically apply; consent is desirable but not required where risk of serious harm persists. ^[2]
• Minimum necessary: share facts (what was seen/heard, when, who was present), not speculation; include capacity status and the adult's stated wishes. ^[5][6]
• Audit trail: record what was shared, with whom, how (phone/email/portal), date/time, and any reference numbers; store acknowledgements. ^[3]

Recording essentials for optical settings

• Clinical context: symptoms, findings, and pertinent negatives (e.g., "no trauma consistent with bruising reported"). ^[3]
• Safeguarding content: verbatim quotes in quotation marks, behaviour observed, explanation given, inconsistencies, and whether private time was offered. ^[4]
• Decisions and roles: advice sought, escalation route chosen, safeguarding lead involvement, and partner feedback; include follow-up tasks with owners and deadlines. ^[4][6]

Systems and prompts that support good records

Electronic systems can prompt for safeguarding fields and support secure attachment of letters, photos (if policy permits), and referral forms with metadata (patient ID, date/time, author). For domiciliary visits, add environment notes (privacy, hazards, controlling individuals) and lone-working actions taken. ^[3]

Good records reduce re-traumatisation and enable partners to act.^[7]

References (numbered in text) Why we include references

1. Information sharing: advice for practitioners providing safeguarding services — Department for Education Find (opens in a new tab)
2. A 10 step guide to sharing information to safeguard children — Information Commissioner's Office Find (opens in a new tab)
3. Patient records — College of Optometrists Find (opens in a new tab)
4. Record Keeping – LLR SAB Multi-Agency Policies & Procedures Resource — Policy Partners Project Find (opens in a new tab)
5. The Caldicott Principles — National Data Guardian Find (opens in a new tab)
6. Decision-making and mental capacity (NICE guideline NG108) — NICE Find (opens in a new tab)
7. Trauma informed practice — NHS Safeguarding (NHS England) Find (opens in a new tab)