Effective Reporting and Record-keeping in Health &Social Care

Effective Reporting and Record-keeping
in
Health &Social Care
1

Contents
Effective Reporting and Record-keeping in Health &Social Care..............................................1
INTRODUCTION...........................................................................................................................3
TASK 1............................................................................................................................................3
Legal and regulatory aspect.........................................................................................................3
Key legislation.............................................................................................................................4
Maintaining the CQC compliances..............................................................................................5
TASK 2............................................................................................................................................6
The process of storing of records in care home firm...................................................................6
The reasons for sharing information within own setting and with external bodies.....................7
External and internal requirements for recording information in own care setting.....................9
Technology can use in recording and reporting own care setting.............................................10
Benefits of involving service user in record keeping process...................................................11
Accurate, concise record for different service user...................................................................12
CONCLUSION..............................................................................................................................13
REFERENCES..............................................................................................................................15
2

INTRODUCTION
Recording keeping have been considered as important aspect in the healthcare setting. In
the social care field, respective data are considered to very delicate for proper effectiveness in
completion of different activities. It is very much important to keep up proper record keeping in
healthcare setting to make up decision in favour of patients. In the health care sector, legal and
regulatory compliance are very much strict limiting up in laws and regulation.
Recording keeping are major role in both external and internal aspect of care setting. The
application of regulatory and legal aspect has proper implementation of technology with
reporting up proper mechanism serving their purpose of care setting. Hence, the care setting has
need to be abide with proper law and regulation ensuring up perfect reporting and record keeping
in view of local and national policies of business environments. The report will have the
inclusion of all perspective regarding information management in the care setting in perfect
manner.
TASK 1
Legal and regulatory aspect
As per the given scenarios, the firm have failed in areas of record keeping and reporting
such as inaccurate medical records, fire safety records not updated, incidents not reported
correctly in line with RIDDOR. The scenario showing up the clear importance of legal and
regularity aspect in healthcare setting. There is major proper compilation of the report on data
base management process in health acre departments and social centers. This includes up proper
description regarding important laws needed around health care setting and business aspects.
Record keeping revolves around the laws and regulations dealing with information which are
confidential in ethical manner. A health care center has information about a person which ae not
needed to be share with anyone without having concern form authority or the person. Health
care departments in UK have been made up with two important things very clear as anything the
individual writes up in relation to work have to be clearly mentioned in health care records.
3

Key legislation
As per case study, ABC care home is based on the company that provide the facilities and
services of people. The importance of enterprise to keep up to date maintain or gathered data. In
order to create or develop an accurate report in proper manner. Regulation and legislation are
considered to be simple ways to make sure the health care professionals to practice in safe
manner throughout the year. This are clearly designed to have limitation over risk which an
individual is face during the treatments. In the UK healthcare, the legislation doesn’t only apply
to individuals, but it is successful in covering up many areas including up range from hospitals
to equipment and medicines. Operational manager needs to identify that how care service is
doing well within specific time intervals. There are the different ways in the healthcare working
out suitable manner mainly known as statuary regulation and later on implemented as law.
Health and social care act 2012
This act has been introduced up as under the first legal duties about different health
inequalities taking place in health care centers. This has clear inclusion of the respective duties
for different health bodies including up the Department of Health, Public Health England,
Clinical Commissioning Groups, and NHS England. In ABC care home, manager is still focus
on their client and get personal detailed. At that time, it is important for establishing a better
relationship with client and share more information regarding overall enterprise.
These body have clear requirements over reducing major level of inequalities between people of
England helping out changing in structure of local authorities on public health function in perfect
manner. This act has inclusion up of differ provision which is helpful in guiding up health care
setting by adopting up favorable practices towards the norm of record keeping and reporting.
On the other hand, the health care professional has need to set in boundaries over
releasing up health records. this is helpful in outlining the protection over patient information’s
along with establishment of criminal penalties over violation. The law applies to hospitals,
medical practices, chiropractors, dentists, nursing homes, pharmacies, and psychologists. On the
other hand, the laws will also have inclusion of their business activities or administration which
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are such as third-party administrators, pharmacy benefit managers for health plans, billing and
transcription companies, and professionals performing legal, accounting, or administrative work.
The reporting provision will be successful in ensuring up the accountability due to registered
person have the need to report to higher authority. Under the regulations, patients must be
notified of any unauthorized access or use of their information. This will make proper abiding for
report keeping as per guideline of laws and regulation.
Data protection Act 1998
In the compliance Data protection Act 1998 is serving the purpose in proper manner as
there have been proper implication of the general data protection regulations or GDPR insuring
up safeguard form information obtained up from health care setting in perfect manner. the
GDPR is successful in operating and regulating up information in the lie of confidentiality of
information needed by organization. Another reason for sharing information is to establish a
good interaction with staff members. In order to identify their specific need or requirement. It
may support for improving the care home services while handling record of individual people in
proper manner.
Maintaining the CQC compliances
In order to maintain the CQC compliances have to meet up key lie enquires set up by the
Care Quality Commission. There is need for care home to be safe, effective, caring, responsive
and well-led. There are many factors which have need to influential in maintaining up these
requirements as health care records are creating the positive impact in fulfilling the standards.
keeping the history is synchronized way is making up the health care providers a more
responsible, organized and responsible in manner. In order to meet up the effective requirements
which are majorly outlined by their CQC. They will be able to get into documents which is
successful in showing up all treatment and documents with residential proof as expected the
heath care have been delivered. This will be helpful in creating up better accountability along
with ensuing the staff for taking up responsibility given to all resident. Keeping the all-resident
plans at one place will automatically increase the accessibility helping the care provider to attain
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up CQC compliance. The purpose has need to be very important proving up appropriate care
and improve the wellbeing of receiver.
On the other hand, it is very important for the health care setting to come up with social
values helping out in reduction of the local inequalities, improve the health and wellbeing of
local people. Hence in longer term reduce the demand on health services and other services.
Consequences of Non-Compliance
This can be identified as the cascading effect proving up the quality of care to the patients.
The health care setting is following up the poor procedure of practices, this will be leading to
have increase in patient issues. Beside these consequences, health care setting will be identified
as several penalties and files tremendously impacting up organizational fees. It helps to monitor
or track the progress of each and every employee. In this way, they can achieve desirable goal
and objective. Noncompliance with records keeping and reporting will lead to major criticism
for health care setting. The auditing errors and several issue in patient health leading to death
can be the reason for deterioration of brand images of health care setting. Hence it is very
important for individuals to keep in major check over records and report filling up in proper
knowledge regarding each patient.
TASK 2
The process of storing of records in care home firm
In ABC Care home, individual needs some extra help to continue living independently and
family are not position to support them, residential care is considered as the best solution. As per
case study, ABC care home is based on the company that provide the facilities and services of
people (Gong and et.al., 2020). The importance of enterprise to keep up to date maintain or
gathered data. In order to create or develop an accurate report in proper manner. Generally, it
should follow the different processes of storing record of individual people.
 Ensure that all type of files or written information become exist within confidential
nature and stored data securely (Gong and et.al., 2020). File should only be accessed by
people who have an equal right and authorized.
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 Personal information regarding the service users, staff members should not keep on
laptops, used as USB sticks or similar devices, unless authorized by manager. This will
help for protecting the personal data or information with device (Gong and et.al., 2020).
 It is important to keep record data within encrypted format so that it should maintain
extra protection. All type of files created or moved to another folder automatically.
 After the documents have arrived that secure archive facility, manager of ABC care home
and other team member can provide a full indexing service. It allows to full of inventory
within individual file within documents that are going into storage.
Documents enterprise manager should keep on hand
Additionally, it is important thing that exactly which business documents that keep to
record data or information regarding health and social care (Gong and et.al., 2020). Sometimes,
it may vary depending on the rules and regulation of ABC care home firm. In additional, here are
some general way to identify the process to keep record.
 Manager should keep to record data or information by authorized people, who have
acknowledged and documented in proper manner.
 It should maintain all essential details of individual record issued with at least one
identification mark of staff members and his signature. Afterwards, it should maintain
computerize the records for quick retrieval.
 Capture the information- In ABC care home, Manager is responsible for handling the
large amount of information or data. Get in touch of capturing everything as start
business and their services. It keeps track of every amount manager spend on the
enterprise and take care every detailed (Gong and et.al., 2020). Manager should have
performed the different process that help for acquiring more detailed about overall
business services.
The reasons for sharing information within own setting and with external bodies.
Confidentiality is central part of trust between manager and other individual people who
have taken the services from ABC care home. The important aspect of sharing the information
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with individual people and other external bodies. The primary reason for establishing a good
interaction between external bodies and care agency. This will help to identify the different
practices regarding the possible services (Cornick, 2019). in order to respect the wishes of both
parties those are not consent to share confidential information.
In ABC care home, manager is still focus on their client and get personal detailed. At that
time, it is important for establishing a better relationship with client and share more information
regarding overall enterprise. There is good reason to share information such as protect or secure
safety at risk (Gong and et.al., 2020). When sharing or requesting personal information from
someone, be certain of basis upon which manager is doing so.
In ABC care home, manager should consider all safety and well-being of individual
people, giving the better supports. Based on the information sharing decision on considerations
of well-being and safety of every person who may be affected by multiple actions.
According to given scenario, it has been focused on the employees which providing the better
training session by trainer (Bowring and et.al., 2019). In this way, they can improve their own
skill and knowledge to set up health or social care setting. These are considered the most
effective way to represent the importance of sharing information. Another reason for sharing
information is to establish a good interaction with staff members. in order to identify their
specific need or requirement. It may support for improving the care home services while
handling record of individual people in proper manner.
Here, it can be identified the reasons for sharing health and social care related
information with other external bodies.
 Improving the links between public protection forum which providing the safeguard for
staff members and another individual person. Through this way, it helps for identifying
the multi-agency risk assessment, health and well-being board and community safety
partnership. These are considered as important aspect of every community to establish a
good coordination between them (Ajao, Officer and Olawale, 2020).
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 Whenever, manager can share the information or data that help for developing a joint
approach in order to resolve dispute between them. It is not obvious thing who have not
responding properly.
 Partner agencies are enquiring to handle the safeguard meetings and investigations. It
keeps informed or record data, which always supports for identifying accurate result or
outcome.
 Monitoring the information at the time of sharing between service provider and other
external bodies (Ajao, Officer and Olawale, 2020). In order to provide the better way to
resolve issue of staff members and other individual people.
External and internal requirements for recording information in own care setting
In ABC care home, manager is focused on the delivery the best quality of health and social
care service on the basis of its mandate or directive manner. At certain, it should be considered
all resources that help to record large amount of information or data as execution of business
processes.
Keep recording the data or information which is consider as essential part. If time
consuming and often perform activity for care service staff members. it must keep different kind
of record, all of which contribute in some different manner (Ajao, Officer and Olawale, 2020). it
is important part of record the performance of staff members on weekly, monthly or on term
basis. It helps to monitor or track the progress of each and every employee. In this way, they can
achieve desirable goal and objective.
For keep recording information, it should consider both internal and external requirements
regarding legal aspects for keeping of record (Ettore and et.al., 2020). According to health and
social act 2008, service provider who do not have relevant data in term of well-being, safety of
their service users. There are different requirements to keep certain kinds of records in proper
manner.
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 In term of regulation 20 (1a), Manager must keep records and relevant documentation
about the person needing the care services.
 In regulation 20 (1b), ABC care provider must keep corresponding record about the staff
members employed to give service. Sometimes, rules and regulations does not spell out
what type of information record and require for management purpose. In this way, it
should clearly record information through legislation as well as regulations.
In ABC care home, Manager is mainly focused on the external requirements that help for
recording information or data related health & Social care. The extent of recording data will
depend on the type of information and sources, overall timeframe of registry. Basically, it may
consider two important drivers behind need for data recording (Ajao, Officer and Olawale,
2020). Externally, it driven to refine or improve quality of data and keep protect or secure in
proper manner. External driven change needs arise for recording new information about the
health and social care. Within system of ABC care home, it becomes available regarding new
therapies which are introduced into healthcare practices.
Technology can use in recording and reporting own care setting.
In ABC care Home, operational manager has faced several challenges regarding the
efficiency and performance. Sometimes, it will increase as issue or problem among staff
members and unable to access information because of service barriers. In this way, manager is
mainly focused on the implementing as ERP system or tool that help for collecting or gathering
all essential demand of individual person. The use of ERP system can lead to fundamental re-
design of home care processes based on the use and integration.
An ERP (enterprise resource planning) system have provided the better way to the
business processes, take care of essential need or requirement. In ABC care home, Operational
manager needs to identify that how care service is doing well within specific time intervals. So
as customized the report from ERP database which are consider as critical way (Ajao, Officer
and Olawale, 2020). Afterwards, getting information so that management can make a better
decision which require to create or develop a strong reporting capability.
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Here are different ways having a strong ERP system which simplifies recording and
reporting health or social care related service.
 By using ERP, manager will create or run their own reports from financial data save
every time and efforts. Sure, that care home enterprise has implemented as business
intelligence system with easy-to-use platform. But there are lot of efficiency gain as
many times greater than cost (Ajao, Officer and Olawale, 2020). Without ERP, self-
service reporting is not possible.
 ERP is helping in another way such as external reporting. It should maintain all
regulations and other external bodies do not get access to ERP system but it is only need
data or information from its nonetheless. Having a single source of all type of outbound
data relieves a lot of stress. Thus, manager of ABC care home can send particular data or
information regarding health and social care to their client. Whenever data stored in ERP
system which make up system of record.
 An ERP system is also combined with the database system just as source of information
or data for corporate reporting. It is important to require for combining with database in
order to produce a meaningful report (Ajao, Officer and Olawale, 2020). This becomes
reliable and feasible for every staff member to manage and control complex data or
information in proper manner.
Benefits of involving service user in record keeping process
In health and social care, it is necessary that patient record is kept and stored in proper
way. the records need to be maintained of service user so that insight is gained about their needs,
wants, etc. there are some benefit of involving service user in record keeping process. It is as
follows
Record management- it is core benefit of involving service user in record keeping. In this they
allow in maintaining of records according to user needs, history, etc. Hence, records are stored
and maintained in segregated way. The service user is able to relay on those records that are
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kept. Along with that, service user is aware of what type of record is to be kept, where, etc.
(Magill, and et.al., 2018)
Effective record keeping- this benefit state that involving service user in record keeping helps in
effective record. The data gathered from them is proper and also it is known to them that what
type of info is to be provided. Therefore, there is no false data records that is being kept. Besides
service user suggest ways as well that how data records can be kept. Thus, quality of data is
maintained as well in it.
Address complaints easily- it is a benefit in which service user data is already stored and kept.
Thus, there is decrease in complaints which are been done from end of service user. Along with
it, there is no requirement of legal process that is followed in it. thus, it helps in delivery care
services quickly and in effective way.
Better communication- there is better communication between multi professional teams. As
records are already kept or stored so those who are involved in providing care to service user are
able to communicate in better way. besides that, info shared is accurate and flow of
communication improves (Haque, and et.al., 2018).
In addition, record keeping helps in making continuity of care easier. There is disruption
of care as service user already known their own info. hence, in case of any requirement is there
then info is retrieved from service user only. Moreover, it supports in doing care home audit,
allocating resources, etc. besides that, there is proper and timely delivery of service. The record
keeping also enable in showing that how decisions are taken and made in it. So, these all are
some benefits of it.
Accurate, concise record for different service user
For different service user the records vary from one another. This is because records are
based on patient info and history. So, they have to be accurate and precise. Similarly, here some
record is prepared that is as follows:
Incident report form- It is a document that is related to any event which has occurred and caused
injury to service user. Thus, it is used to record entire incident and damage done, safety issues,
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etc. in case service user has incident of physical abuse then the form is filled with help of
accurate records and info. in this there are many things included such as
Date, name, location, witness
What happened and how,
Who was involved in it?
Safety precautions
Health care plan – as name depicts it is a plan which consists of entire plan of service user. It
shows that what type of care is to be provided, when, how, etc. the document gives insight to
doctor and nurse that how treatment is to be given. In this it must be updated, provide info about
condition of patient, documented clearly, and consistent.
Complaint form- it is a document that is related to complaint regarding any service given to
patient. here, all details regarding person involved, type of care given, procedure followed, etc. is
written and all other details are recorded into it. In health care setting because will gain
knowledge about legislation and protocols and all those requirements (Lai, and et.al., 2020).
set in place. Is important to have information about all service users in any aspects of life like
physical and mental wellbeing because will be stored securely.
There is a responsible record keeper for answering to parliament, and the manager of care
setting to observe all shared information between bodies. Regulatory requirements provide that a
lack of agreement go to punishment. Hence, these all are some documents of service user that
require precise info to be written. The forms are necessary as it gives info about patient condition
and details.
CONCLUSION
From the above file, it can be concluded as Reporting of practicing and recording keeping
Very delicate ensuring high level of perfectness and effectiveness in completion of different
activities. The care setting has need to be abide with proper law and regulation ensuring up
perfect reporting and record keeping in view of local and national policies of business
environments. In the UK healthcare, the legislation doesn’t only apply to individuals, but it is
13

successful in covering up many areas including up range from hospitals to equipment and
medicines. Patients must be notified of any unauthorized access or use of their information. This
will make proper abiding for report keeping as per guideline of laws and regulation. CQC
compliances have to meet up key lie enquires set up by the Care Quality Commission. The
auditing errors and several issue in patient health leading to death can be the reason for
deterioration of brand images of health care setting.
14

REFERENCES
Book and Journals
Abbasi, M and et.al., 2018. Identification and management of frailty in the primary care setting.
CMAJ, 190(38), pp. E1134-E1140.
Ajao, R.L., Officer, E. and Olawale, S.S., 2020. RECORD KEEPING AS A MEASURE OF
EFFECTIVE ADMINISTRATION IN SECONDARY SCHOOLS: PLANNING
STRATEGIES. JOURNAL OF CONTEMPORARY ISSUES IN EDUCATIONAL
PLANNING AND ADMINISTRATION. 5(2). p.1.
Bowring, K. and et.al., 2019. Cost-effectiveness analyses using real-world data: an overview of
the literature. Journal of medical economics. 22(6). pp.545-553.
Bridgeman, M.B. and Amazia, D.T., 2017. Medicinal cannabis: history, pharmacology, and
implications for the acute care setting. Pharmacy and Therapeutics, 42(3). p.180.
Cornick, M., 2019. Record keeping and documentation: a legal perspective. Orthopedic &
Trauma Times. (35). pp.34-38.
Council standards', Nursing Management, vol. 25, no. 3, pp. 17-21.
Duffy, K. and Gillies, A. (2018) 'Supervision and assessment: the new Nursing and Midwifery
Ettore, D. and et.al., 2020. Challenges with tracing patients on antiretroviral therapy who are late
for clinic appointments in rural South Africa and recommendations for future
practice. Global Health Action. 13(1). p.1755115.
Gong, M. and et.al., 2020. Cloud-Based System for Effective Surveillance and Control of
COVID-19: Useful Experiences from Hubei, China. Journal of Medical Internet
Research. 22(4). p.e18948.
Haque, M., and et.al., 2018. Health care-associated infections–an overview. Infection and drug
resistance, 11, p.2321.
Kuiper’s, S.J., Cram, J.M. and Niebuhr, A.P., 2019. The importance of patient-centered care and
co-creation of care for satisfaction with care and physical and social well-being of
patients with multi-morbidity in the primary care setting. BMC health services research,
19(1). p.13.
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Lai, J., and et.al., 2020. Factors associated with mental health outcomes among health care
workers exposed to coronavirus disease 2019. JAMA network open, 3(3), pp. e203976-
e203976.
Larocque, F. and Varma, J.K., 2017. A public health approach to hepatitis C in an urban setting.
American journal of public health, 107(6), pp.922-926.
Magill, S.S., and et.al., 2018. Changes in prevalence of health care–associated infections in US
hospitals. New England Journal of Medicine, 379(18), pp.1732
Online
ICO (2017) The Guide to Freedom of Information, [Online], Available through:
<https://ico.org.uk/for organizations/guide-to-freedom-of-information>
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