Effective Reporting and Record- keeping in Health

Unit17: Effective Reporting and Record-
keeping in Health and Social Care Services
Final

Table of Contents
Introduction......................................................................................................................................2
P6 Describe how technology is used in recording and reporting in own care setting.....................2
P7 Explain the benefits of involving service users in record keeping processes.............................4
M3 Review the use of digital technology in relation to own medical management procedures or
care plan...........................................................................................................................................5
D3 Evaluate the effectiveness of the use of technology in terms of meeting service user needs,
ensuring appropriate care is given and maintaining confidentiality................................................6
P8 Produce accurate, legible, concise and coherent records regarding service user care for
different service users following their own setting’s guidelines.....................................................6
P9 Explain different aspects of own management of service user records with reference to
compliance with national and local policies and guidelines............................................................9
M4 Analyse the process of maintaining records in own setting, identifying any potential or actual
difficulties........................................................................................................................................9
D4 Evaluate the effectiveness of own completion of documentation in terms of meeting service
user needs, ensuring appropriate care is given and effective reporting is carried out...................10
References......................................................................................................................................11
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Introduction
This audit report will provide the review of the usage of technology within the reporting and
recording of the service user care along with the establishment of the ways to keep as well as
maintain the records of the service users adhering to the legal framework of health and social
care. This report will also include the benefits of the involvement of service users within the
process of record keeping. It will also include a discussion regarding the use of digital
technology within the medical management procedures or care plans along with the relevant
difficulties and benefits. This will be followed by the evaluation of the technology within
meeting the needs of the service users while ensuring that adequate care has been provided along
with the maintenance of confidentiality.
Audit Report
An audit report is referred to as the written letter from the auditor comprising of their opinion
regarding whether the financial statements of the organisation adhere to the generally accepted
accounting principles (GAAP) and are free from material misstatement.
P6 Describe how technology is used in recording and reporting in own care setting
The records of the patients have rapidly turned out to be digitized. Electronic Patient Records
(ERPs) allow real-time sharing in and throughout the boundary of care. The digital interventions
in the ERP, for instance, Computerised Physician Order Entry (CPOE) or electronic prescribing
(prescribing) can minimise the risk of error (Solomon and Rudin, 2020). The delivery of care to
the patient is reliant on efficient communication between the staff and patients and the healthcare
staff. The digital environment has now been providing new as well as exciting ways for
increasing the processes. The norm in modern healthcare is multidisciplinary working which
means that the accessibility and contribution towards the ERP are related to all of the individuals.
The increased usage of digital records means that huge volumes of digital data are being
produced which can be utilised for encouraging the improvement in quality within healthcare
(Gianfrancesco, Tamang, Yazdany and Schmajuk, 2018).
Smartphones can be used to communicate medication adherence education; information related
to behaviour change and follow up treatment protocol to the providers and members through
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managed care plans. Making records at the point of care with the tablets decreases the time
which is spent on documentation. Along with this, the usage of tablets assists in the avoidance of
burdensome and error-prone entry of human data. They provide assistance with the elimination
of human-introduced errors for instance within the data entry through the input in the data from
patient care systems (Gianfrancesco, Tamang, Yazdany and Schmajuk, 2018). By eliminating the
requirement of recording information on paper, tablets have saved money, energy, time along
with making improvements within the efficiency.
The use of tablets has also allowed quick access to information whenever it is required by
healthcare professionals. Tablets have also assisted in the reduction of messy paperwork as well
as the manual workflow processes in turn leading to increased efficiencies. The multimedia,
visual and graphics abilities can be leveraged for recording as well as providing on-demand
information, for instance, the progression of the disease, visual images of the patients as well as
sounds, for example, irregular heartbeat (Solomon and Rudin, 2020).
Technology supported consulting is considered by various individuals as the partial solution
towards the complex challenges of delivering healthcare to eth increasingly diverse and ageing
population. Remote consultations provide prospective advantages to the patients and healthcare
system. Virtual clinics through Skype have been utilised for counselling and mental health
consultations. Skype has proved to be an efficient medium for providing support to the
independence and self-confidence of young individuals. Virtual clinics are responsible for
bringing specialist care to patients’ homes (Greenhalgh et al., 2016).
It is an ideal solution for allowing the patients to have access to specialist care; however, without
unreasonably exposing themselves to the high-risk environment. These clinics also minimise the
need for travelling to or from the hospitals which is also a considerable benefit as about 20 per
cent of the traffic within the UK is attributed to travel related to healthcare. Furthermore, virtual
clinics mean that less time is missed from the work which can be a recurrent challenge for the
individuals; hence, this minimisation within treatment burden is highly advantageous (Quinn,
Davies and Hadjiconstantinou, 2020).
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