Effective Reporting and Record-keeping in Health and Social Care

Effective Reporting and
Record-keeping in Health and
Social Care

Table of Contents
Describe the legal and regulatory aspects of reporting and record keeping in a care setting..........3
Explore the internal and external recording requirements in a care setting.....................................4
Describe how technology is used in recording and reporting in own care setting..........................7
Explain the benefits of involving service users in record keeping processes..................................8
Review the use of digital technology in relation to own medical management procedures or care
plan..................................................................................................................................................9
Produce accurate, legible, concise and coherent records regarding service user care for different
service users following own setting’s guidelines..........................................................................11
Explain different aspects of own management of service user records with reference to
compliance with national and local policies and guidelines..........................................................14
Analyze the process of maintaining records in own setting, identifying any potential or actual
difficulties......................................................................................................................................15
Conclusion.....................................................................................................................................17
REFERENCES..............................................................................................................................18

Describe the legal and regulatory aspects of reporting and record keeping in a
care setting
There are several practices for reporting as well as recordkeeping which are very essential in
healthcare setting. These are the activities which are used in social care field in effective manner.
As this field is very delicate committed essential to manage the use of data source information
and ensured perfection and high level of effectiveness of several operation. This is also involved
in ensuring that recordkeeping within areas of health and social wellbeing are very impactful for
linking with external aspects (Akhigbe, Amyot, and Richards, 2019). There are several link
within the internal environment of a care setting that are managed properly. In context of
application within regulatory and legal aspects of practice, it is considered that implementation
of technology within recordkeeping practices and reporting mechanisms are very important for
providing services in care setting. It is very important for this type of organization to manage
laws and regulations properly for managing local as well as national policies.
Legal and regulatory aspects
When management is asked for preparing and compiling reports on data management and
process in health and social care, there is need to manage the legal and regulatory aspects
effectively. There is description within laws and regulations of healthcare for managing various
aspects of healthcare practice. There are several aspects of recordkeeping around regulations and
laws which are used for dealing with information in ethical and confidential manner. It is seen
that information sharing is very important while managing the data and information. In context
of care setting, there are several highly personal information regarding a patient and it is legal to
take protection of these regulatory requirements. It is also essential for maintaining level of trust
and loyal David patients and enhance the level of patient’s safety in organizational premises. In
the present scenario, recordkeeping is the most centrally organised way for the health and life of
patient (Char, Abràmoff, and Feudtner, 2020). There is need to manage the reporting of data
source information and take care of relevant people connected to the healthcare field. There is
need to manage regulatory obligation regarding patient and it is responsibility of authority and
management to share relevant and sufficient information with the 3rd party. In context of
individual neighbour, family, friend , professionals to take care of several individuals within
health and social care workers. There are legal and regulatory requirement that information has
to be handled and protective with care. It is also ensured that protection and authentic use of data

and information associated with patient must be taken care in health and social care. There are
several practices for keeping as well as maintaining records in proper manner and providing
delivery to patients by concerning their personal practice activities. There are some legislations
as well as laws involved in maintaining records and reporting them. According to the Data
Protection Act 1998, there are proper guidelines provided to healthcare management 2 avoid
spreading of information regarding patient to other people (Crowley and et.al, 2020). This is
involved in general data protection regulation and it is ensured that data and information of any
patient is not provided to other people. The process of recording, holding, disclosing and using is
associated with whole process of data protection. In context of whole process, it is seen that the
Data Protection Act 1998 is associated with managing confidentiality of information and
managing need of information for data and protection of patient. In context of care setting, there
are several ways for registered person on protecting and making information safe from any kind
of misuse and exploitation. The health and social Care Act 2008 states that there are different
provisions that must be Provided to the management of healthcare in order to adopt favourable
practices within recordkeeping and reporting. In context of the present scenario individual
information is leaked and his records were not maintained effectively in the care setting. It is
responsibility of management to have non compliance with recordkeeping and reporting which
can lead to criticism within care setting. Consequences for avoidance of legal regulatory in
health and social care can even lead to death. Hence, it is essential for the medical organizations
to take care of patients safety in order to keep the trust and loyalty among patient and healthcare
setting.
Explore the internal and external recording requirements in a care setting
Requirements of internal and external recording
According to the scenario given in the case, it is clear that legal regulatory within healthcare
management must be adopted in order to have better consultation about patients. It is important
for all people to consult with legal regulations and protocols in order to know about internal and
external recording in care setting. There are several local hospitals which refuse to record
patients condition which can lead to problem in future. If a family member had a power of
attorney for the patient and refusal to provide access to record from the medical organization is a
proof for lack of compliance with law. It is also important to have the data and information from