Effective Reporting and Record Keeping in Health and Social Care Services

Effective Reporting and Record
Keeping in Health and Social
Care Services
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Table of Contents
INTRODUCTION...........................................................................................................................3
TASK 1............................................................................................................................................3
P1 Provide an introduction of your organization which clearly evaluate the current digital and
manual process.......................................................................................................................3
P2 Explain the reasons for sharing information within own setting and with external bodies.
................................................................................................................................................4
TASK 2............................................................................................................................................5
P3 Identify statutory requirements for reporting & record keeping for your health care setting
meeting the requirements of a inspecting body......................................................................5
P4 Based on above identified statutory requirements, demonstrate the internal and external
requirements for recording information in own care setting..................................................6
External requirements for recording information in Caring Homes Ltd are discussed below.
................................................................................................................................................6
P5 Explore the consequences of failing to comply with requirements of statutory and
inspecting bodies....................................................................................................................6
TASK 3............................................................................................................................................7
P6 Review and evaluate the effectiveness of the use of digital technology to meet the service
user needs, ensuring appropriate care is given while maintaining confidentiality.................7
P7 Explain the benefits of involving service users in record-keeping processes in your care
setting.....................................................................................................................................7
TASK 4............................................................................................................................................8
P8 Produce digital care plan and evaluate the effectiveness in terms of meeting the service
user needs...............................................................................................................................8
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P9 Conclude with recommendations for improvements within your own practice...............9
CONCLUSION................................................................................................................................9
REFERENCES..............................................................................................................................10
INTRODUCTION
Reporting and record keeping are the most important aspects of a health and social care
practitioners. An accurate report or record keeping is necessary in healthcare sectors as it forms
an essential part of delivery of care or management of the service users (Alfoghi and Ramadan,
2017). However, it also helps in circulation of information between different teams which are
involved in treatment of patient. In this report, Caring Homes Ltd has been chosen. It is a
healthcare organisation in UK which provides support and care services to the citizens of UK
with a chain of care facilities for the individuals. The following report is going to cover Internal
and external recording requirements in a care setting. Furthermore, it will focus on Legal and
regulatory aspects of reporting and record keeping .At last Use of technology in reporting and
recording will be cover.
TASK 1
P1 Provide an introduction of your organization which clearly evaluate the current digital and
manual process
Caring Homes Ltd is a health and social care sector which provide care facilities to the
individuals of United Kingdom. The respective organisation goes through digital and manual
processing for keeping records of their service users. The digital process use by the organisation
in respect to patient records are discussed here.
Storing: It is a computer based record keeping. Records of the patients are stored in a
system and which is design to provide store all necessary data of patient treatment. It provides
accurate alerts, data, clinical support systems and provide links to medical knowledge.
Maintaining: Electronic health record is a method for maintaining records of the
patients. It provide space for patients demographics, medical histories, diagnosis, immunization
dates and many more.
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Sharing patients records: IT digital systems are available nowadays for sharing
information of the patient treatment across external and internal department with could be
handled remotely.
Manual process for record keeping in respective organisation is discussed as follows.
Storing: It is basically a book keeping or documentation where the records are stored and
maintained through hand process. Information of the patients are handled by care practitioners
itself by maintaining a file or document.
Maintaining: Records of the patients are maintain in a document and calculations for the
bill and audits are done in a file and are mostly hand written.
Sharing patients records: Information regarding patient treatment are shared by
transferring of file from one department to another. Documents are shared between care
practitioners for sharing information.
Difficulties were faced during maintaining and storing of patients records manually. As it
is a hand written process there are chances of risks and errors that could be occur and it is then
risky for the patient if they get any wrong treatment (Chauhan and et.al., 2016). Thus, along with
being beneficial maintaining and storing records digitally are easy and it gives accurate data
along with proper access to all necessary information needed for the treatment process of service
users.
P2 Explain the reasons for sharing information within own setting and with external bodies.
Information sharing is a process of passing information from one department to another.
All health and social care organisation are required to share information of the patients they are
looking for within the department and to external bodies for improving the quality of care
delivering to the patients. In Caring Homes Ltd it is essential to implement information sharing
process in order to deliver high quality of services to their service users. It is important to share
information within the care settings as it helps to develop a stronger relationship between the
care practitioners and help them to solve problems more effectively (Cornock, 2019). It enables
faster decision making process as it include the views and opinions of different professionals
within the organisation. Sharing health records of patients will help to improve specific
treatment, speed up diagnosis process, and enables care practitioners to plan new treatment or
make necessary changes in the treatment process.
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