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Effective Reporting and Record Keeping in Healthcare : Assignment

Added on - 23 Nov 2020

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Effective Reporting andRecord Keeping
INTRODUCED......................3MAIN BODY..................................................................................................................................3TASK 1............................................................................................................................................3Statutory requirements for reporting and record keeping in own care setting............................3Regulatory and inspecting bodies' requirements for record-keeping and reporting in caresetting...........................................................................................................................................4Process of storing of records in own care setting........................................................................5Reasons for sharing information within own setting and with external bodies...........................5Internal and external requirements for recording information in own care setting..................6Implications of non-compliance with legislation, regulating and inspecting bodies’requirements................................................................................................................................6TASK 2............................................................................................................................................6Use of technologies in reporting and record-keeping in own care setting..................................6Benefits of involving service users in record keeping processes................................................7Accurate, legible, concise and coherent records..........................................................................8Different aspects of own management of service user records...................................................9Effectiveness of use of technology in terms of meeting service user needs................................9CONCLUSION..............................................................................................................................10REFERENCES..............................................................................................................................121
INTRODUCEDRecord keeping and reporting are synonymous. An effective patient care needsdocumentation of future plans, treatment and diagnosis so that, sharing of communication forevery practitioner for benefit of patient. Several civil cases develop after initial event, records areimportant to provide content, accuracy, clarity, style and comprehensiveness. In a recordeverything should be mentioned such as date and sign. Aim of record-keeping should be accurateand non- offensive and should not breach patient confidentiality(Stavropoulou, Doherty andTosey, 2015). It can be either hand written or can be maintained with the help of electronicdevices. This assessment will include legal and regulatory aspects of record keeping andreporting and also how technologies are used to keep record and reporting.MAIN BODYTASK 1Statutory requirements for reporting and record keeping in own care settingClinical record keeping and reporting is integral part in a good professional practice andprovide a good quality of healthcare. Clinical record-keeping and reporting should changecontinuity of care and also enhance interaction between different professional of healthcare.Accurate written record and report detailing every aspects of the patient monitoring is essentialnot because it forms integral part of provision of nursing management or care of patient but alsoit contributes to circulation of information among different teams interested in patient's care ortreatment. A legal sense, record-keeping and documentation is also there for protection ofhealthcare professionals or healthcare. The new General Data Protection Regulation is that DataProtection Directive, underpinned by number of principle of data protection that drivecompliance( Wuellner and Bonauto, 2014). GDPR requires that data controller provide datasubject with the information about patient's personal data processing in concise, intelligible andtransparent that easily accessible and different from other task between data subject andcontroller using plain and clear language.Any organisations which publishes, analyses and collects confidential health andinformation of care should follow codes of practice on confidential information. It defines stepswhich organisations may and should take ensure, confidential information handled appropriately.This code will help organizations to put right procedures and structures in place so front line staff2
can follow the confidentiality rules. It gives a good practice guidance for those individuals whoare responsible for meeting and setting organisational policy on handling of care information andconfidential health like board members. These types of requirements are essential to reportingand record-keeping, it helps to maintain a good quality of data and information about all thepatients which is required to maintain. This information is required for any policy developmentand implementation.Regulatory and inspecting bodies' requirements for record-keeping and reporting in care settingKeeping records and reporting is important patient and care employees. It is vital whichstaff are given training for reporting and record keeping, which is need to update and referring.The Fundamental Standards that national healthcare system has to apply in order to maintainregistration of service with care quality commission. These are designed to maintain reportingand record-keeping. The code of ethics and standards of the professional conduct is ethicalbenchmark for the investment professionals around globe. The CFA institute code of ethics andprofessional conduct are the fundamental to values of CFA institute. Inspecting bodyrequirements are essential in healthcare. By inspecting care people help to ensure if healthcareservices which are meeting needed standards of care and this good practice is recognized andareas of betterment are addressed. These inspectors are undertake unannounced and announcedinspection of the healthcare services. This involves physical inspection of clinical areas and alsointerviews of patients as well as staff(Feng & et. al., 2014). Care quality commission regulatesall social care and health services in United Kingdom. This commission ensures safety andquality of care in healthcare. This commission provides care at home with help of trained staffwho collect the whole information about the patient and keep it safe for their care and treatment.Healthcare can face implications if it fails to comply a good care and service. And it isvery important to maintain a proper information about patient and patient's medication. Ifhealthcare fails to provide it can lead to enforcement notices, legal actions and monetary penalty.Enforcement notices are type of notice which are received by healthcare in case inspectioninspector comes and investigate and does not find proper care and data management of patientsat that time this notice is sent to that healthcare. Health and safety executive launchedinvestigation into Ramsay health care in UK, it was because of the internal occupational healthservice was run. And healthcare has to pay some amount as a penalty in such cases and alsosome legal action can be taken against the particular healthcare.3
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