Effective Reporting and Record keeping in Health and Social Care Services

This presentation discusses the significance of reporting and record keeping in health and social care services. It covers the statutory and regulatory requirements, the process of storing records, reasons for sharing information, and the internal and external requirements for recording information.

Effective Reporting
and Record keeping
in Health and Social
Care Services

Table of Content
• Introduction
• Statutory requirements for reporting and record keeping
• Regulatory and inspecting bodies’ requirements
• Process of storing of records in own care setting
• Reasons for sharing information
• The internal and external requirements for recording information
• Conclusion
• References

Introduction
In every organisation reporting and record keeping is essential. It is
considered as the process of recording events as well as transactions. It is
an crucial aspects of health and social care services. Effectual record
keeping is helpful to promote patient care as well as better
communication

Statutory requirements for reporting and
record keeping
Reporting and record keeping is essential for both patients as well as
for healthcare firm. While maintaining relevant and accurate records
company can facilitate better quality of services to their employees and
patients. In health and social care, reports and records are kept with the
use medical record numbering, dividers, folders and so on.

Cont...
The statutory requirements for keeping records are set in regulations 20
of Health and social care Act. So, its requirements in Core Havencare
Ltd. are as follows:
• Care records - Care services must be capable to show that keep
records of care and treatment are facilitated to all services user.

Cont...
• Access to records - Records are available to service user or legal
representative concerned care and treatment. For example: someone
lacks mental capability to make decision on Core Havencare Ltd.
And employees. Thus, all should have knowledge about where
records and reports are kept and to access them

Regulatory and inspecting bodies’
requirements
Regulatory and inspecting bodies are considered as government agency
which is established to perform a regulatory functions. Many regulatory
bodies protect public from various health risk and facilitate numerous
events for people health and welfare. Some regulatory body in health
and social services are heath and safety authority, mental health
commission, medical council and so on.

Cont...
Failure to comply enforcement notice: Enforcement notice is
considered as a formal document which creditor issue to debtors,
providing warning about taking action to cover owed money. If Core
Havencare Ltd. Failure to comply enforcement notice in that case
notice of prosecution should generally obey.

Cont...
Due to this some consequences happens in Core Havencare Ltd. such
as loss of trust, dignity, privacy etc. that are mentioned below:
• Loss of trust
• Loss of dignity

Process of storing of records in own care
setting
In health and social care records are stored as it facilitates the relevant
as well as exact information about patients details, treatments that is
given to them and so on. Process for storing paper documents like
clinical notes, incident report etc..

Cont...
In Core Havencare Ltd. Records are store through following process:
• At first the forms are obtained
• Reports are started
• Basic facts are facilitated
• Involve line regarding nature of incidents

Cont...
Process for storing patient information in Core Havencare Ltd. Are as
follows:
• Care plans
• Nutrition recording
Process of maintaining confidentiality in Core Havencare Ltd. Are:
files of people are locked and secured, data are not told to anyone,
patients medical, details are not explained without its consent.

Reasons for sharing information
This is very important for the health care providers to secure the data
and the information of the patients and these data should not be shared
with any other third party without the information of the patients.
Whereas sharing the information for treatment of the patient is
considered as one of the main aim which helps in providing better
treatment to patients.

Cont...
The doctors are required to carry on the reports to the other
professionals so that they are able to achieve the objective of treating
the patients in better way. This would help them to have a better
treatment and would also help the patients to be cured as early as
possible.

Cont...
The information that has to be shared to the external bodies includes
that hospital should share the information in the secure and proper
manner so that information is not shared with the third party while in
transit. These information should be shared securely through the
electronic forms having the security which is accessible by the end
user.

The internal and external requirements for
recording information
Recording of data of patients, employees, etc. at Core Havencare Ltd.
can be done with the help of some sources. As there are many
departments in Core Havencare Ltd., so with these resources data can
be handled with care. There is requirement of internal as well as
external recording requirements which helps to maintain proper records
of related parties of Core Havencare Ltd.

Cont...
Internal recording requirements:
• Medical history
• Test and treatments
• Medical management plan
• Service user form

Cont...
External recording requirements
• Management of Health and Safety at Work Regulations (1999)
• Reporting of Injuries, Diseases and Dangerous Occurrences
Regulations (1995)
• Workplace (Health, Safety and Welfare) Regulations (1992)

Conclusion
From the above report it is concluded that, health and medical care
reporting and recording is one of the main process which helps in
keeping the record of the patients information. There are various ways
that are included in providing the information of the service users. As
there are various legal and regulatory aspects which are used for
reporting and record keeping in the care setting which the medical
practitioners should take care.

References
• Fleissig, A. and et.al., 2017. Multidisciplinary teams in cancer
care: are they effective in the UK?. The lancet oncology. 7(11).
pp.935-943.
• Dziegielewski, S. F., 2018. The changing face of health care
social work: Professional practiceinthe era of managed care.
Springer Publishing Company.

Thank You