Effective Reporting and Record-keeping in Health & Social Care

This document discusses the importance of reporting and record-keeping in health and social care settings. It covers the statutory requirements, regulatory bodies, and implications of non-compliance. The document also explores the process of storing records, reasons for sharing information, and the role of technology. Additionally, it highlights the benefits of involving service users in record-keeping and emphasizes the importance of accurate and coherent records. The document concludes with insights into the management of service user records and evaluates the effectiveness of documentation.

Effective Reporting and
Record-keeping in Health &
Social Care

Table of Contents
INTRODUCTION...........................................................................................................................4
MAIN BODY...................................................................................................................................4
TASK 1............................................................................................................................................4
P1) The statutory requirement for reporting and record keeping in own care setting ...........4
P2) Describe the regulatory and inspecting bodies requirement for reporting and records
keeping in a care setting.........................................................................................................6
M1) The implication of non compliance with legislation, regulating and inspecting bodies
requirement.............................................................................................................................6
D1) Evaluate the consequences of non compliance with references to the media service safety
and the credibility of the care setting ....................................................................................7
TASK 2............................................................................................................................................7
P3 Describe the process for storing of record in own care setting. .......................................7
P4 Reason for sharing information with external bodies or within own settings...................8
P5 internal and external requirement for Record Keeping in own care setting .....................8
M2 current processes in own care setting regarding and storing and sharing record.............9
D2 evaluation on per setting arrangement and processes for sharing information and storing
along with recommendation for improvement.......................................................................9
TASK 3............................................................................................................................................9
P6 Describing the role of Technology in recording and reporting in own care setting..........9
P7 Benefit of involving service user in Record Keeping processes.....................................10
M3 Use of digital technology in medical management processor for care plan..................10
D3 Effectiveness of use of Technology in term of service user needs and to maintain
confidentiality.......................................................................................................................11
TASK 4..........................................................................................................................................11
P8) Produce accurate, legible, concise and coherent records regarding services user care for
different services user following own setting guidelines ...................................................11
P9) Explain different aspects of own management of services user records with references to
compliance with the national and local policies and guidelines ..........................................12

M4) Analyse the various process of mainlining records in their own setting, identifying any
potential or actual difficulties...............................................................................................13
D1) Evaluate the effectiveness of own completion of documentation in term of meeting
services user need, ensuring appropriate care is given and effective reporting is carried out13
CONCLUSION..............................................................................................................................13
REFERENCES .............................................................................................................................14

INTRODUCTION
The reporting and record keeping are important in the particular healthcare. There are
various activity which is useful in the social care and this provide to store data and all. The field
is very clear and this will provide the use of data or information in perfection and this provide
high level of effectively of activities. In the social and health care units it is well analyse to
create the high level of effectiveness of activities. As per this, the record keeping is major step
which is involved in maintaining the higher storage of patient data. There are various number of
decision which is taken in favour of patient. This is ensure that the record keeping is the area of
health and social well being is essential in order to patients. In addition to this, the legal and
regulatory parameter in health and social care for the health and social care. In this context, the
requirement for record keeping may not necessary in order to link with external aspects but they
also associated with the internal environment (Frost and et. al., 2017). There are number of
application which is based on regulatory and legal aspect of the rational practice. Moreover, in
the care setting should be abide by law and regulation. This help to ensure about law record
keeping and keeping local and national policies. This report covers the all perspective of the
record and information management which is important in care setting.
MAIN BODY
TASK 1
P1) The statutory requirement for reporting and record keeping in own care setting
Legal and regulatory aspect
A scenario help to answer on legal and regulatory aspect in the given case study which is
regulated by the National health services. They ordered the national regulator to compile a report
on data management and process of health and social care centre. The description is usually
related with the aspect of various law and regulation which help to know the fact within the
aspect of its practices (Manogaran and et. al., 2017). In the regulation of record keeping the law
and regulation which is dealing for various information that is confidential and ethical.
Moreover, the information sharing which is usually drive in order to take place with various
people who required additional information which is constantly saving and attaching with
various data base. This all aspect is a regulation of a person in authority in care setting which is
help to share information. The person which may be friend, family member and professional

taking care of the individual. In this the social care or health care worker and this provide the
individual or worker who is fulfilling the various responsibility of providing social care and
healthcare need to individual in the care setting.
This is also defined with the legal and regulatory requirement which required the
information which is take place in the social and healthcare. Handling of information which is
important because this is involve protection and authentic use of information of any individual
taking the aspect of health and social care needs. There are various practice which is help to
involve in maintaining records of information which make required outcomes for those who
want information in future for references. There are some law such as data protection act 1998
offers various guidelines in this regards. In this, the general data protection regulation or GDPR
which is helpful in this regards. The process of holding, recording using and disclosing
information which make the whole process of data protection. As per this, the data protection act
help to make ensure about the data confidentiality of information and the need of the
organisation for the information (Ngiam and et. al., 2019).
In a health and social care setting, it is an essential for a registered person on the scene to
protect and make the information safe from misuse and others. The health and social care act
2008 provide the guide in the health and social care setting. The reporting provision in the law
and regulation which must be provide proper accountability because the registered person has to
report in a person in higher authority. Moreover, the care setting which help to provide the
practice that practice the record keeping and reporting. There are reporting provision in the law
and regulation that help to ensure the accountability because the registered person has to report
in the higher authority. The law and regulation is can come up with the expectation of the
national regulator after the various sad demise in the care setting.
Consequences of Non- compliance:
In the present scenario the individual is died due the the ignorance of record which is not
maintained with care setting. Non compliance as with taking consideration to the record keeping
and and reporting which has lead criticism in the health and social care. Death as result with the
collective ignorance in health and social care has neglected in the image of the setting which is
highly essential in older with diagnose report and their testing report. As per this, they can cause
and help the care setting which may be knowledge of every patient (Singh and et. al., 2019).

P2) Describe the regulatory and inspecting bodies requirement for reporting and records keeping
in a care setting
Record keeping include all the various aspect of paperwork which need to be kept by the
care provider while in your application in the reasons such as health safety and legal protection
finance, registration and also used in the context with the patient medical history. Completing
this project it all are required a mass of paperwork to kept in a particular area and they need
proper attention and safety e in a terms of privacy. Care provider records and records keeping
system must in a form of collaboration and they are came in existence of care standard and
regulation. The general data protection law they have been truly revised with effect from may
2018. The regulating and inspecting body are used to see and visualize the records and reports in
a proper manner. As per this, the authority and boards member are making their standard
operating procedure in which the collect the relevant data which may be regarding to finance and
other parts which show the sensitive content and confidentiality. The legal requirement which is
used in the keeping of records are regulated in the sector of health and social care which is is
regulated by law which is based on health and social care act 2008 and 2010s. There is
legislation are used in health and social care to maintain the record in order to provide the patient
history and their consequences. Inspecting body and regulating body have a different technique
to store the data in appropriate manner for the longer period of time and such a way which help
the service provider to provide quality of health care to patient.
M1) The implication of non compliance with legislation, regulating and inspecting bodies
requirement
As per the scenario, the new staff which assign in a health and social care must know
about the compliance with patient. This is better to know the law and regulation and various
protocol in the requirement of internal and external requirement. In this they are noticed and
verified by the death of patient where in the major of cases this is well identified by checking
their medical history to ensure that the death is natural. This records are must share with family
and their member in order to know the various complication as per this they are being in position
to died (Venkatesan and et. al., 2018).

D1) Evaluate the consequences of non compliance with references to the media service safety
and the credibility of the care setting
There are a number of consequences which is related to the compliance like the breaching
health and safety regulation is a criminal offence. This in the provision to an enterprise that is
breaching legislation and this can cause high penalty and fine. There are various issues which
may arises in the context to the industry disqualification and also damage the reputation of firm.
As per this, the media server safety and the credibility of the care settings is very essential in
order to maintain the record keeping and maintain the confidentiality of report. There are number
of consequences such as paying fines and penalties which is higher in amount are the
consequences which is arise in this.
TASK 2
P3 Describe the process for storing of record in own care setting.
There are some standard which has been fixed by the government in relation to storing of record
in an own care setting. Some process which are discussed further. There is first creation of
registration number which is there a unique identifier (alphabetical prefix numerical number) of
each and every record which can help to find out in future. This is able to help you to provide an
evidence that record is created or captured. After this, there record is keep in the either in paper
or electronic record which contain each and every description and all the patient who are there
for getting record (March, 2018).
All the information which is regarding the present is collected and all the report which is
regarding health of the patient is noted there with correct time. There are different types of files
which are like created as a record employee files in personnel department, supplier files in
purchasing department, patients file in community or Hospital settings, client file in community
setting etc. To create a record of the patient there is need to collect all the right information
regarding their health. There is need to update all the new information about that patient. There is
need to provide present information of patients care along with its condition. There is need to
create the information in such a manner that in future it will provide each and every small
information about the recent health (Lee and et. al., 2018). There is need to keep in mind that all
the the initial data which include date, time, entry should be noted clearly. Record should Store
securely in relation to give the required information and follow the local policy.

P4 Reason for sharing information with external bodies or within own settings
There are many reasons for sharing information of any patient which is either in on
setting care or with external bodies. In this, there are many reasons and which one of the specific
reason is to provide better care and treatment to that patient. This is one of the main reason to
share the information regarding the patient's health in own care setting. Share the information
gives better knowledge about the patient health that can physician or medical practitioner is able
to get the health information about the present and provide accordingly better treatment. Sharing
of information about the patient with in own care setting also helps to identify any new way to
treat better. This can help by sharing the recent information regarding health with other medical
practitioner or physicians. This sharing can help to get each and every physicians view that can
find out easiest way to treat to provide better treatment to that patient. Sharing information
regarding their patient with other physician can help to find out new way on new technique for
better treatment (Davies, 2017). There is also a sharing of information with the nursing staff who
are there to provide better service and care to the patient. Nursing staff is able to take care of
each and every activity of present that is from providing medicine on time to the time when the
patient is getting discharge after treatment. Sometimes there is a need to share the information of
the patient with external bodies. This is the condition when there is some order from court
regarding sharing of information of patient. It is illegal or unethical to share of information with
external body. There is need to keep in mind that the patient information is getting shared with
external body should we agree about that. When information of the patient is suffering with
external bodies then other body should be closer to the patient and patient is not able to provide
any caretaker for him or her. In this case information regarding the patient can be shared with
external bodies that are their parents or their guardian. This can also be done when there is any
order or warrant has taken to collect information of that patients health that can help in to resolve
any case. Without concern of the present, there should not be sharing of health information of
that patient with anyone either they are their family member or close friend (Bender, 2017).
P5 internal and external requirement for Record Keeping in own care setting
There are many internal and external requirement for recording information in own care
setting. There are some of the internal requirements for record keeping is that this information
can help in the future to get the reference. It also helps to know the medical history that can help
in to treat better of diseases who have the patient acquired. Internal Record Keeping can help

patient and doctors of physician to provide better treatment according to medical history of that
patient. There are some of the external requirement for record keeping which are like to show as
evidence about health issue to show as an evidence to legal authorities. Internal requirement for
help identify the medical history which is related with the case and this can also help and
beneficial for the patient when this information is for good news (Granados-Chinchilla, 2017).
M2 current processes in own care setting regarding and storing and sharing record
In relation to storing and sharing of record of the patient, is one of the high priority for
health care setting and is there is need to keep in mind that there should not be any leak of the
information that can used for negative action. There is collection of all the information in one
place as a record. There all the information is there with the name of physician or doctor under
which patients was getting treated (Bomberg, 2017).
D2 evaluation on per setting arrangement and processes for sharing information and storing
along with recommendation for improvement
It can be seen that all the information about the patients health should not shared with
anyone without the concern of the patient. To store all the data of each and every patient, there is
a storage room where all the records are kept with their unique numbers.
Recommendation- It is recommended that there is need to focus moron record sharing of
the patient without concern. There is need to keep the information in a safe place where no one is
allowed without the permission and authority to that place. There is also need to focus on the
process in which the medical history is being prepared and recorded (Agüero, 2017).
TASK 3
P6 Describing the role of Technology in recording and reporting in own care setting
There are different role of technology in recording and reporting in own care setting in
which some of them are going to discuss further. Technology play an important role in
healthcare. Each and every test require use of different type of technology that is in their
machine. So, it can’t be denied that technology is not involve in his care setting. In relation to
keeping record is also require a role of technology. There are many patient and each have their
own health record. So, in relation to record them all in proper manner computer are used.
Computer is able to keep all the information of either of soft document or physical evidence
information (Matar and et. al., 2018). Electrical information refers to information or data that is

collected on electronic device like computer, laptop etc. Physical information refers to
documentation for creating a file images of paper. It is hard to find each and every present record
in current time manually. So, there is use of technology which is able to find information about
any patient just by entering their name, age and many more. Technology is there, that can help to
collect all the information on the single platform that is able to access by any corner of world.
This can help to share the medical history of the patient with other health professional as per the
requirement. Technology have the high role in sharing and collecting information (Kaipio,
2017).
P7 Benefit of involving service user in Record Keeping processes
There are many benefit of involving service user there in the process of record keeping in
healthcare or own care setting. There are many benefits and some of the benefits which are
discussed further.
Involving the service user who is there in own care setting that shows that, there is
transparency during the record keeping and creating a record. This transparency says that there is
no change in the record keeping in comparison to actual process. Involving the service user
during the Record Keeping process says that there is their accountability. Involvement of service
user record keeping also confirms that there is no interchange in the record keeping or any type
of misconduct during recording the information and data. It also provide benefit that involving
the service user shows that they are being participated in their Healthcare role where during the
recording of health of that service user. Involvement of service user also help in improvement in
the service which is there provided by the health care setting. This helps in to improve the quality
of public health activities like patient was suffering from long term illness (Wade and Halligan,
2017). They are able to get better treatment and proper care. Involving service user can provide
better potential in relation to accessibility and acceptability of health services. There is higher
and better quality of services are being delivered in relation to provide better treatment to the
patient.
M3 Use of digital technology in medical management processor for care plan
First of all, there are many different data technology are used in medical healthcare
management procedure and care plan. In an Healthcare services from starting to end, there is use
of digital technology. During entry, there is a need for the registration process where computer is
used to create the entry of patient initial information about that patient. In own care setting each

and every process either diagnosis or treatment. There is use of digital technology during
diagnosis. There are different machines are used for this diagnosis process which is an example
of digital technology. Digital technology also use to share the information with other physicians
or doctors who are in other corner of world. This sharing information help to get the latest
knowledge information about the treatment (Partridge and Gallagher, 2018).
D3 Effectiveness of use of Technology in term of service user needs and to maintain
confidentiality
Technology is used during recording of information about the patient health involvement
of service user shows that there is no change of information in the record. It also ensure that
service is there about each and every processor and information. This also ensure the service user
about each and every procedure and information. Technology provides better security to the
access for files and folders. Involving the service user in process of record keeping give the
confidence about security of data. In relation to maintain confidentiality of the record of patient,
involvement of service user who have the right to have their information safe and not to share
with anyone (Blakey, 2017).
TASK 4
P8) Produce accurate, legible, concise and coherent records regarding services user care for
different services user following own setting guidelines
Record keeping is the key channel which is provide the integrated services to the children
and their families and carers and terms of this. The consistent recording process are essential for
the planning of services and also helpful in taking that is season and information sharing quality.
Recording with a employing the number of ways is used to provide documentary evidences of
the authority and the involvement within the usual service user. There are number of recording
which is used to finalize in three working days for the event. The service users and care are to be
informed of the right to access their records and they have a proper guidelines. Which used to
provide the standard operating procedure to maintain the content and correcting errors. As per
the disagreement of records. So, this is an accurate and process which is used in the matter of
coherent records regarding services and all the section of this portfolio is to maintain the service
user and service provider must maintain that at of firm by providing quality of health and quality
of care to the number of patient (Lemieux, V.L., 2017). As per this, there are various set of

guidelines which is usually follow in the childcare setting or the health care setting. They have
proper standard operating procedure which must need to follow by the organization or industry
in order to maintain the harmony and decorum for this. Rules and regulations the health and
social care act provide a brief knowledge about the record keeping and how effective record can
maintain which is helpful for the form in order to provide best asses to patient for their safety
and medication.
P9) Explain different aspects of own management of services user records with references to
compliance with the national and local policies and guidelines
Record management is defined as the record and information management in which the
organizational structure is maintained in such a way which is help to to make a collaborative
organization. As per this, life cycle the creation of receipt to the eventual. This position is
necessary because it help to identify, classifying, story retrieving, securing tracking and
destroying for permanently. Preserving the records is useful for the history of medical checkup
of any patient or any other terms in the healthcare organization. The institutional memory is very
important and it have to maintain in order to provide the best possible treatment or diagnose that
is redevelop or recreated after analyzing the last data which is recorded and preserved in the
databases. There are various guidelines is associated with the local policies and international
guidelines. Overall, the local policies and guidelines are usually circulated or regulated in
manual to create the confidentiality in terms of record or services. There are various aspect
which is usually follow and context with sector by creating tough and possible strategies and
plan which is implemented to make a possible compliance. To maintain the record it is must
analyse to follow the local policies in terms to create an interventions to keep the record for the
longer period of time in order to provide increased information of any patient for any
complications. The proper education is essential to maintain the record with the proper date and
with the proper time. The local policies are circulated and such a way to maintain the
correspondence feature which is available and the rewards the advanced technology such as
computer and laptops are used in effective way to maintain the data and the backup for the
longer period of time. This allow user to enable the data and search as per their requirement
(Lewis, K., 2019).
principle of good record keeping
 Be factful and consist and accurate for the keeping of record.

 Be updated as soon as possible after the proper record keeping
 provide the proper information which is used to must care and condition of the patinet
and client.
 Provide the documentation which is help provide the clear inm such the way which help
cannot be removed or erdiacte.
This is all are local and national guidelines which is standard in nature and this is usually
followed by the hospital and various organisation in order to associated with principle of record
keeping.
M4) Analyse the various process of mainlining records in their own setting, identifying any
potential or actual difficulties
There are various factor which is mainlining that describe the record in their setting
which is used to identify the potential. There are various process which is used to record the
details in order to prevent the hardness which is caused by due to improper data of any patient in
the health and social care the potential which is arises in the maintaining of records. In health and
social care unit is very essential and such a way that help of patient to know their past
complications and disease to create the medication and diagnose in order to keep the previous
history in the mind. Usually doctor and physician analyse their behaviour bye maintaining the
records and fulfilling the medication or the diagnose need of any patient (Bird,2017).
D1) Evaluate the effectiveness of own completion of documentation in term of meeting services
user need, ensuring appropriate care is given and effective reporting is carried out
There are effectiveness which is own completion of the documentation which is create an
effectiveness. This is the proper effectiveness the compilation of the document and in terms of
meeting services and ensuring the various form of reporting which is carried in organization with
the purpose of providing essential and evaluated medication and treatment to the patient in order
to improve their quality of life. As per this, there are major factors which help to create the
valuable chain and atmosphere in the workplace as per the designing of essential quality of care
which help by maintaining the records in effective way which is carried out for the future aspect
for the longer period of time (Ashariand Pramusinto, 2018).

CONCLUSION
As per the above discussion, this is well analyse that the record keeping is an effective
way which help them to maintain the factor which is enormous in nature can cause the proper
record keeping. In context with this, they can help in providing the quality of life and this will
eradicate the issue which is associated with additional factor.

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