RCGP Safeguarding toolkit
The aim of this toolkit is to enhance the safeguarding knowledge and skills that GPs already have to enable them to continue to effectively safeguard children and young people, as well as adults at risk of harm.
Part 4: Documenting safeguarding concerns and information
Safeguarding codes
There are now multiple codes that can be utilised for recording safeguarding concerns and information in the electronic medical record, with new codes frequently being developed. There are different clinical IT systems used in general practice across the four UK nations which use different coding systems.
The table below provides a list of essential safeguarding codes. Regular and consistent use of these codes will ensure a common safeguarding language and understanding across general practice.
Situation and relevant codes to be used as Major Active/Significant Problems
SNOMED CT ID (SCTID)
Read V2
CTV3
Safeguarding concern about a child, including an unborn child.
The relevant code should be recorded in the child’s records as well as relevant family member records.
The relevant code should be recorded in the child’s records as well as relevant family member records.
Child is cause for safeguarding concern
836881000000105 | Child is cause for safeguarding concern (finding) |
13WX. | Child is cause for safeguarding concern |
XaZJs | Child is cause for safeguarding concern |
Child in family is safeguarding concern
1064961000000107 | Child in family is safeguarding concern (situation) |
No current active map or equivalent.
XafeJ | Child in family is safeguarding concern |
Unborn child is cause for safeguarding concern
878111000000109 | Unborn child is cause for safeguarding concern (finding) |
13If0 | Unborn child is cause for safeguarding concern |
XaaNV | Unborn child is cause for safeguarding concern |
When a child is on a child protection plan/register.
The relevant code should be recorded in the child’s records as well as relevant family member records.
The relevant code should be recorded in the child’s records as well as relevant family member records.
Subject to child protection plan
342191000000101 | Subject to child protection plan (finding) |
13Iv. | Subject to child protection plan |
XaOnx | Subject to child protection plan |
Family member subject to child protection plan
375041000000100 | Family member subject of child protection plan (situation) |
13Iy. | Family member subject of child protection plan |
XaPkF | Family member subject of child protection plan |
Unborn child subject to child protection plan
818901000000100 | Unborn child subject to child protection plan (finding) |
13Iv0 | Unborn child subject to child protection plan |
XaYs9 | Unborn child subject to child protection plan |
No longer subject to child protection plan
342891000000105 | No longer subject to child protection plan (finding) |
13Iw. | No longer subject to child protection plan |
XaOtl | No longer subject to child protection plan |
Family member no longer subject of child protection plan
375071000000106 | Family member no longer subject of child protection plan (situation) |
13Iz. | Family member no longer subject of child protection plan |
XaPkG | Family member no longer subject of child protection plan |
Unborn child no longer subject to child protection plan
1025431000000104 | Unborn child no longer subject to child protection plan (finding) |
13Iw0 | Unborn child no longer subject to child protection plan |
XaeDd | Unborn child no longer subject to child protection plan |
When a child becomes a Looked After Child.
The relevant code should be recorded in the child’s records as well as relevant family member records.
The relevant code should be recorded in the child’s records as well as relevant family member records.
Looked After child
764841000000100 | Looked after child (finding) |
13IB1 | Looked after child |
XaXLt | Looked after child |
No longer subject of looked after child arrangement
764951000000107 | No longer subject of looked after child arrangement (finding) |
9NgF. | No longer subject of looked after child arrangement |
XaXMD | No longer subject of looked after child arrangement |
Transition out of youth care system (ie care leaver)
770347003 | Transition out of youth care system (finding) |
No current active map or equivalent.
No current active map or equivalent.
Approved foster parent
314381008 | Approved foster parent (finding) |
133N. | Approved foster parent |
XaF0D | Approved foster parent |
Member of foster family
224104006 | Member of foster family (finding) |
No current active map or equivalent.
Ua0Hw | Member of foster family |
Own child has been fostered
183433004 | Own child has been fostered (regime/therapy) |
8GE71 | Own child has been fostered |
8GE71 | Own child has been fostered |
Own child has been adopted
160866002 | Own child has been adopted (finding) |
13I81 | Own child has been adopted |
13I81 | Own child has been adopted |
When a child is designated as a Child in Need.
The relevant code should be recorded in the child’s records. In relevant family record’s a code such as ‘Child in family is safeguarding concern’ should be recorded.
The relevant code should be recorded in the child’s records. In relevant family record’s a code such as ‘Child in family is safeguarding concern’ should be recorded.
Subject of child in need plan
836931000000102 | Subject of child in need plan (finding) |
8CM5. | Child in need plan |
XaZKA | Subject of child in need plan |
Child no longer in need
135890008 | Child no longer in need (finding) |
13IT. | Child no longer in need |
XaIO7 | Child no longer in need |
When a child is an unaccompanied child asylum seeker.
The relevant code should be recorded in the child’s records.
The relevant code should be recorded in the child’s records.
Unaccompanied child asylum seeker
748241000000103 | Unaccompanied child asylum seeker (person) |
No current active map or equivalent.
XaWvm | Unaccompanied child asylum seeker |
When there is an adult safeguarding concern.
The relevant code should be recorded in the adult’s records. Consideration should also be given as to whether any information needs to be recorded in any other records, such as relevant family members.
The relevant code should be recorded in the adult’s records. Consideration should also be given as to whether any information needs to be recorded in any other records, such as relevant family members.
Adult safeguarding concern
766561000000109 | Adult safeguarding concern (finding) |
9Ngj. | Adult safeguarding concern |
XaXP4 | Adult safeguarding concern |
Domestic abuse and MARAC.
(PLEASE ALSO REFER TO THE SEPARATE GUIDANCE ON RECORDING DOMESTIC ABUSE)
(PLEASE ALSO REFER TO THE SEPARATE GUIDANCE ON RECORDING DOMESTIC ABUSE)
History of domestic abuse
429746005 | History of domestic abuse (situation) |
14XD. | History of domestic abuse |
XaN21 | History of domestic abuse |
Subject of multi-agency risk assessment conference
758941000000108 | Subject of multi-agency risk assessment conference (finding) |
13Hm. | Subject of multi-agency risk assessment conference |
XaX96 | Subject of multi-agency risk assessment conference |
When any safeguarding document contains third party information.
This code should be recorded in the patient record and linked to the document.
This code does not have to be placed in the Major/Active Significant Problems.
This code should be recorded in the patient record and linked to the document.
This code does not have to be placed in the Major/Active Significant Problems.
Record contains third party information
888931000000108 | Record contains third party information (finding) |
9lL.. | Record contains third party information |
Xaai0 | Record contains third party information |
When a child or adult is not brought to an appointment.
This code should be recorded in the patient record.
This code should be recorded in the patient record.
Child not brought to appointment
901441000000108 | Child not brought to appointment (finding) |
9Nz1. | Child not brought to appointment |
Xab0Q | Child not brought to appointment |
Adult was not brought to appointment
1323481000000100 | Adult not brought to appointment (finding) |
No current active map or equivalent.
No current active map or equivalent.
When an adult is subject to public protection arrangements (MAPPA in England, Scotland and Wales, PPANI in Northern Ireland).
This code should be recorded in the patient record.
This code should be recorded in the patient record.
Subject of multi-agency public protection arrangements
495021000000105 | Subject of multi-agency public protection arrangements (finding) |
13Hl. | Subject of multi-agency public protection arrangements |
XaQGW | Subject of multi-agency public protection arrangements |