Effective Record Keeping and Documentation

The assignment discusses the significance of record keeping in healthcare settings, emphasizing the need to follow legal statutory requirements. It covers various aspects, including producing records for different service users, managing patient data, and ensuring effective documentation and reporting processes. The report also touches on training programs for staff and conducting regular feedback sessions with patients and their relatives.

EFFECTIVE REPORTING
AND RECORD KEEPING IN
HEALTH AND SOCIAL
CARE

TABLE OF CONTENTS
INTRODUCTION...........................................................................................................................3
P8 Production of records regarding service user care for different service users.......................3
P9 Different aspects of own management of service user records..............................................3
M4 Process of maintaining records in own setting, ...................................................................4
D4: Effectiveness of own completion of documentation ...........................................................4
CONCLUSION................................................................................................................................5
REFERENCES................................................................................................................................6

INTRODUCTION
This section of the report focus upon the elements of an effective record keeping process. Along
with it, the report will also cover basic laws related to medical record keeping process within a
healthcare setting.
P8 Production of records regarding service user care for different service users
Surrey and Sussex has adopted several types of records' outlet for keeping the records of
different service users for better accessibility. It has been found out that availability of different
formats for service users including elderly patients, children and critical patients is required
(Gorst and et.al., 2016). An effective record keeping facilitates minimum work load and help in
increasing the efficiency and productivity of the entire task force. Here, Surrey and Sussex
hospital has implemented all types of record keeping parameters for minimizing the burden and
eases off their employees by minimum paperwork. This is possible only through adopting the
methodology that focuses on clarity, conciseness, completeness.
In regard to the same, this hospital administration has used software to keep details about
all the patients under separate functional units. For instance, the first timer has to register it
properly and thus the next time, the patient has to only pay the amount and straight away meet
the doctor or attend the testing. This makes the functionalities at the hospital more accessibility
and convenient with an emphasis on giving more clarity in performing the jobs at hand.
Additionally, a robust record keeping at this hospital is divided into two administrative units, one
is for the employees and the other one is for the patients. This involves complete information
about the address, salaries etc. and the patients' data and information consists of treatment plan,
medication information, doctors' remarks and others. Along with, Surrey and Sussex hospital has
developed highly standardized recording system that are exploratory in nature and can easily
read basic information written in health record.
P9 Different aspects of own management of service user records
Management of service users records within any healthcare setting can be done by
adopting suitable laws applied to medical record management programs. Patients' records related
to severe chronic diseases must be secured in a proper area. Hospitals must have an allotted area
to store health records (Mastebroek and et.al., 2014). As per the record management guidelines,
hospitals must a proper designated team to cater all record keeping procedures which may
includes the clinical members and non clinical staff as well.

There are number of legal obligations that any hospital need to consider while record
keeping processes. As per the Public Record Act, 1958 hospitals need to maintain health data
such as birth and death certificates for at least 10 years of time period. Before dissolving health
records, hospitals are responsible to circulate proper notice to public to accumulate any missing
health certificates. It should also follow the Freedom of Information Act, 2000 in which there
need to be a proper description of elements mentioned in a health record.
M4 Process of maintaining records in own setting,
Surrey and Sussex hospital uses different tools to record health data of its patients
effectively by adopting policies of NHS. Hospital focuses on constructive process to train its
staff for managing all forms of report according to standard protocols and coding system.
Management of records within selected hospital is carried out by inclusion of specified system
software. Computerized Patient records are being effectively designed by healthcare
professionals of hospitals.
Identifying any potential or actual difficulties
Potential issues which may arise while maintaining records are ineffective or untrained
professionals to handle system software or hospital information systems. Along with it, training
programs by management team also play a vital role in reducing issues related to digital
recording and record keeping process.
D4: Effectiveness of own completion of documentation
In terms of meeting needs of service users, documentation must be completed with full
information related to patients' details, their contact number and other government identification
documents. Furthermore, specifications to health issues with proper hospital identification and
bed number must be mentioned. For fulfilling needs of service users, hospital may plan a regular
feedback process for its patients and their relatives to assess the loopholes of the hospitals.
For ensuring appropriate care to the patients, hospitals need to conduct plan for training
programs of clinical and non- clinical staff (Bates and et.al., 2014). There must be a proper
segment of effective reporting and recordings of health data that would facilitate patients as well
as clinical staff.

CONCLUSION
The above report has defined that record keeping must follow all required legal statutory for its
record maintenance and reporting process. Along with the above mentioned acts, Data protect
Act 1998 and its policies must also be considered for health recording and reporting systems
within hospitals.

REFERENCES
Books and Journals
Bates, D.W. and et.al., 2014. Big data in health care: using analytics to identify and manage
high-risk and high-cost patients. Health Affairs. 33(7). pp.1123-1131.
Gorst, S.L. and et.al., 2016. Choosing important health outcomes for comparative effectiveness
research: an updated review and user survey. PLoS One. 11(1). p. e0146444.
Mastebroek, M. and et.al., 2014. Health information exchange in general practice care for people
with intellectual disabilities—a qualitative review of the literature. Research in
Developmental Disabilities. 35(9). pp.1978-1987.