Record Keeping and Reporting Guidelines

The provided document discusses the significance of record keeping and reporting guidelines within the health and social care sector. It highlights various types of guidelines and principles that organizations must follow to ensure compliance with laws and legislations. The non-compliance can lead to enforcement or money penalty notices for care homes, which may also damage their reputation. Furthermore, it emphasizes the importance of honesty, integrity, privacy, and respect as fundamental standards set by laws for healthcare professionals.

HEALTH AND
SOCIAL CARE
Contents

INTRODUCTION...........................................................................................................................1
TASK 1............................................................................................................................................1
LO 1.................................................................................................................................................1
P1 Statutory requirements for record keeping and reporting in own care settings......................1
P2 Regulatory and inspecting bodies’ requirements for record keeping and reporting in care
settings.........................................................................................................................................2
LO 2.................................................................................................................................................4
P3 Process of storing of records in own care settings.................................................................4
P4 Reasons for sharing information in own settings with external bodies..................................4
P5 External and internal requirements for recording information in own care settings..............5
TASK 2............................................................................................................................................6
LO 3.................................................................................................................................................6
P6 Describe how technology is used in recording and reporting in own care setting.................6
P7 Explain the benefits of involving service users in record keeping processes.........................7
LO 4.................................................................................................................................................8
P8 Production of records regarding service user care for various service users following own
setting guidelines.........................................................................................................................8
P9 Different aspects of own management of service user records in compliance with local and
national policies...........................................................................................................................8
CONCLUSION................................................................................................................................9
REFERENCES..............................................................................................................................10

INTRODUCTION
Health and social care refers to the services concerned with social support, care and
protection given to adults or children while they are in medical need or at risk owing to poverty,
old age, disability, illness etc. (Kotronoulas and et. al., 2014). The healthcare sector is required to
work in accordance with the legislations stipulated by law as the professionals working as a part
of this profession deal with the lives of people and their one wrong act can lead to adverse
outcomes for individuals. This sector is governed by the jurisdictions and guidelines given by
The National Health Service and Community Care Act, 1990. The following report is based upon
Barnet Hospital which is a district hospital located within Barnet, London. The ownership and
management of this healthcare centre lies in the hands of Royal Free London NHS Foundation
Trust. This report includes legal and regulatory aspects of record keeping and reporting along
with external and internal recording requirements within own care settings. Further, it explores
the use of technology in reporting and record keeping. Lastly, it talks about maintenance of
records.
TASK 1
LO 1
P1 Statutory requirements for record keeping and reporting in own care settings
The health and social care professionals deals with the lives of people and work for the
protection and provision of medical assistance or care to people. In this regard, the hospitals or
health care centres working as a part of this sector is required to abide by certain guidelines
associated with reporting and record keeping stipulated by law (Coulter and et. al., 2014). In this
regard, Barnet Hospital also abides by the below mentioned acts and guidelines to ensure
desirable record keeping across organisational premises:-
General Data Protection Regulations (2018): GDPR tends to standardize Data
Protection Law within the all 28 countries of European Union and strives to impose strict
regulations for controlling and processing of Personally Identifiable Information (PII). GDPR
supersedes the UK Data Protection Act of 1998. GDRP tends to emphasize upon the following
principles in relation to personal data of patients:-
 Personal data should be processed in a lawful and fair manner.
 It should be procured for the mere purpose stated clearly.
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 It must be relevant, sufficient and in-excessive for the required purpose.
 Data should be up-to-date as well as correct.
 It should not be kept for a time longer than the requirements of purpose.
 Data should be processed as per the rights of data subjects under the Data Protection Act
(1998).
 Relevant organisational as well as technical measures should be undertaken against
unauthorized use of any personal information or destruction/damage to such data (Eight
Data Protection Principles, 2013).
 Personal data should not be not transmitted external to European Economic Area except
when that nation assures relevant data protection.
Freedom of Information Act (2000): This act stipulated by The Parliament of UK
renders public access to data kept by health and social care organisations. This is carried out in
two-folded ways, namely, HSC authorities have to publish information about their functioning
and public can request information from them (What is the Freedom of Information Act?, 2019).
Human Rights Act (1998): This act brings ECHR (European Convention on Human
Rights) into home law that depicts that all healthcare organisations should protect and respect the
rights of individuals. Furthermore, The Health and Social Care Act (2008) makes sure that
public, private and not-for-profit care homes funded by state abide by the Human Rights Act
which came into force within 1998.
P2 Regulatory and inspecting bodies’ requirements for record keeping and reporting in care
settings
Health care professionals are responsible for taking into consideration the health and
welfare of public. It is essential that HSC professionals maintain adequate records at all the times
so as to ensure minimum or no discrepancy across the organisational premises. The procedural
errors taking place in hospitals with respect to record-keeping may even lead to death of patients.
This may take place owing to missed observations of patients due to inaccuracy within shift
records, erroneous medicine dosage etc. In some cases, even after death of patients, their families
are denied the access to their healthcare records. Taking all these into account, the regulatory and
inspecting bodies lay out certain requirements for reporting and record keeping within hospitals
such as Barnet Hospital as follows:-
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Fundamental Standards of Care: These contain the guidelines and traits stipulated by
law that the health care professionals are expected and liable to comply with in order to refrain
from any kind of legal consequences. The HSC Act 2008 (Regulated Activities) Regulations
2014 consists of 11 fundamental standards, namely, person-centred care, safeguarding from
abuse, privacy and dignity, need for consent, safe care and treatment, fulfilment of nutritional
and hydration needs, good governance, premises & equipments, complaints, fit & proper
personnel employed, staffing (The fundamental standards and the CQC’s guidance on how to
achieve them, 2019). Compliance with all these ensures effective record keeping and reporting.
Regulatory Bodies’ Professional Standards and Codes of Conduct: Honesty and
integrity are regarded to be closely associated with health and social care sector and Professional
Standards as well as Code of Conduct within HSC also emphasize upon this. The Code of
Conduct within Healthcare organisations like Barnet Hospital is made up of values such as
respect, honesty and fairness, service-centred, excellence, culture of commitment which ensures
that records are adequately maintained and reported.
Care Quality Commission (CQC): Inspectors of healthcare sector assess adherence to
record keeping regulations by looking for evidences which depict that care plans are fit for
purpose. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 comprise
of requirements associated with record-keeping requirements under Regulation 17: Good
Governance (Record keeping: In-depth, 2019). In accordance with this regulation, inspectors
ensure the following things with reference to hospital records:-
 Hospitals maintain accurate care, support and treatment records of each patient.
 Healthcare centres ensure that records are secure and confidentially maintained.
 Records are kept for adequate quantum of time.
 Hospitals keep additional records asked to be maintained by CQC with regards to
management of care services.
 Care homes keep records in a secured place so that they are easily accessible.
 Records surpassing the minimum retention time period are securely damaged.
In case the requirements set by regulatory and inspecting bodies are not fulfilled by
health care units, they may get enforcement notice, monetary penalty notice or may even be
asked to undergo audit. Further, the credibility of healthcare professional as well as organisation
will come to stake with the media reports publicising the negative aspects of the entity. A breach
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of requirements stated by inspection and regulatory bodies lead to breach of fundamental
standards such as respect, dignity and trust for HSC professionals.
LO 2
P3 Process of storing of records in own care settings
Storing records of patients for minimum retention period assists healthcare organisations
such as Barnet Hospital in providing the records as and when required by family members of
patients, law or court order. These records are of three types:-
(A) Paper documents: Accident and incident reports or statements, clinical notes, meeting
notes, risk assessment, staff as well as visitor logs
(B) Electronic documents: Lab reports, emails, letters from and/or to healthcare professionals,
text messages
(C) Patient information (electronic or written): Care plans, records of nutrition and medicines,
documents for request and review of tests
Information systems/databases
The types of reporting and recording media include photographs, x-rays, print-outs from
monitoring equipments, videos, recordings of telephonic conversations etc. (Bovaird, Briggs. and
Willis, 2014). This information can also be transmitted by verbal means.
Maintaining confidentiality
Health care records consists of sensitive and personal information about clients and thus
it is crucial for care homes to ensure the security systems under whose surveillance records are
maintained are relevant, reliable and capable of maintaining the confidentiality of data.
Errors in recording and reporting
The data recorded and reported should be accurate to the full knowledge of healthcare
professionals and organisations.
Retention and disposal of records
These comprise of the expectations associated with maintenance of records such as time
boundaries.
P4 Reasons for sharing information in own settings with external bodies
The personal information of clients and other relevant data central to health and social
care settings have to be shared with external bodies owing to certain reasons stipulated hereafter.
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Identifying objectives
The person asking for the information of clients or care home is first enquired about the
objective associated with enquiry of such information.
Consent from service users and/or their advocate/s
If the objective stated by external body seems to be relevant and suitable, consent related
to sharing of personal information of patients is then taken from service users or their advocates.
Implications of sharing without individuals’ knowledge and consent:
If the personal and sensitive information about service user is shared with an external
body without taking prior permission from client, service users or their advocates possess the
right to take legal actions against such hospital (Aarons and et. al., 2014).
Sharing with personnel
The sharing of information can take place with staff engaged in investigating the
complaints, other professionals involved in provision of care or at the time of audits.
Following appropriate court documentation
Post arranging adequate court documentation, health statistics and sensitive information
about service users are shared with external bodies. Also, these external bodies can be
acquaintances or families of patients who are eager on collecting certain necessary health
information of patients.
P5 External and internal requirements for recording information in own care settings
Recording information in own care is basically done on the basis of two types of requirements
that is internal as well as external types. Both of these types includes various terminology in
medical field that are required to concerned by medical staff at the time of record keeping.
Inclusions of internal and external requirement of recording information have been defined as
below:
Internal recording requirements
As per evaluation, it has been analysed that internal recording requirement for medical
staff of Barnet hospital includes medical test reports of patients, past treatment records that is
related to anaesthetics, surgery, complaints, clinical incidents etc. (Pecora, 2018). Diagnosis
reports of patients, telecare recording, medical management plan, timescales, frequency of
recording, records of specialist calls, telephone consultations, forms of service users, signatories
etc. It can be said that all of these provided mentioned internal requirement of recording are
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mandatory to be recorded by medical staff as all of them contributes in formulating better
records that further helps patient in getting better treatment on patient on the basis of these
records.
External recording requirements
Inclusions of external recording requirements involve many of the external records. This
includes health and safety related concerns such as reporting of incidents and accidents and need
of legislation that are related to recording of information in context of health and safety. Along
with this, it further includes various other things like adult or child protection requirements, role
of governmental bodies in record maintaining and reporting concerns. On the basis of these
external requirements it can be said that by fulfilling all of these concerns medical staff can
provide better treatment to patients in future at the time of any uncertainty.
TASK 2
LO 3
P6 Describe how technology is used in recording and reporting in own care setting
Health care industry is highly surrounded with technology as medical staff and other staff
members are aware about usage of technology in maintaining record of hospital effectively. In
context to Barnet Hospital, it can be said that its medical are using different kind of technological
tools in their day to day life in order to perform their regular based activity in effective manner.
For instance: Medical staff of Barnet Hospitals are using different types of gadgets like mobile
phones and tablets in their daily life working practices for recording and maintaining entries of
patients. In addition to this, it has been further realised that technology have been upgraded in
very rapid manner in medical stream as there are numerous mobile application which are
specifically developed for medical stream that also helps nurses and other medical staff in
keeping records of each and employee separately (Nelson and Staggers, 2016). In addition to
this, it can be said that through these applications family members of patients can also access to
information easily that also guides them in providing better treatment to patients.
Along with this, there different governmental bodies like NICE (National Institute for
Health and Care Excellence) which basically provides guidelines to medical practitioners in four
different core areas. These areas include usage of technologies related to health and care sector
that is related to knowledge about existing and new medicines, procedures and treatments. Its
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guidance also involves knowledge on clinical practices that appropriate care and treatment for
patients on particular diseases with specific symptoms too (Donetto and et. al., 2015). Apart from
this, it has also been seen that guidelines provided by this institution is not only limited to
medical staff but they are also helpful for individual involved in promotional activities of health
care sector and for patients as well. This is because by following these guidelines patients
himself can improve their health condition in more effective manner.
P7 Explain the benefits of involving service users in record keeping processes
Record keeping process plays an essential role in the growth of health care industry. In
order to make it more effective health care practitioners are now involving service users in
recording keeping process for enhancing its effectiveness (Greenhalgh and et. al., 2016). In
context to Barnet Hospital, it can be said that there are numerous of benefits which are gained by
medical practitioners of this hospital by involving service users in recording keeping process.
Some of its main benefits are defined as below:
 Involvement of services user that is patients in record keeping process allows medical
practitioners getting access to desired information on which they have to work on priority
basis.
 It also saves resources as well as efforts of hospitals as patients are the only one who
could provide authentic information to medical staff. This further helps them in providing
best treatment to service user on the basis of information provided by them.
 It another benefit could be seen in the form of cost savage. This is because, involvement
of service user in record keeping process does not involve much number of staff members
thus, it ultimately saves cost of hospital as they only have to approach single person
which saves their cost as well as time (Tambuyzer, Pieters and Van Audenhove, 2014).
 Another benefit of patient involvement is that it directly avoids risk of deficiency of skills
of hospital staff. As, it can be said that if medical are not skilled properly then it would
not be possible for them represent actual information in record books which have been
collected by them during medical inspections. It can be said that, this situation can be
avoided effectively if desired record is maintained by involving actual service user that is
patients.
 At next, another benefit of this is related to lack of chances of ethical issue. It can be said
that if patients themselves are involved in their record keeping process then does not
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develop situation of ethical issue. It is because, service user themselves does not record
any wrong information in their records as they know it is related to life.
LO 4
P8 Production of records regarding service user care for various service users following own
setting guidelines
Health and social care organisations have to maintain and preserve strict records of
patients and other key information to produce it as and when required by external bodies. The
records maintained by care homes should be relevant, accurate, up to date, comprehensible,
legible and timely (Cameron and et. al., 2014). Also, the records must be maintained in a concise
manner by making use of relevant and appropriate digital technology. Further, these records
must possess the capability to support the delivery of high-quality care.
Types of records in care practice
A number of record are maintained in care homes such as rotas and timesheets, minutes
of meetings, cleanliness and hygiene records, nutritional status of patients, progress or change
noticed in service users, interventions, specific episodes of care, reporting of accidents, incidents
or near misses.
P9 Different aspects of own management of service user records in compliance with local and
national policies
There are various aspects of management of service user records in compliance with local
and national policies described below.
Using sound numeracy skills
Numeracy skills should be applied by professional in recording information regarding
nutrition and fluid balance, day-to-day administration and maintenance of records, medication
management, monitoring of routine activity, accurate medicines calculations etc.
Recognising and responding to errors and issues
There should be adequate recognition of errors noted on part of professionals or care
homes by service users. Errors can be noticed in relation to recording and reporting, maintenance
of confidentiality and security, accountabilities of staff members, whistle-blowing, compliance
with procedures (Newman and et. al., 2015). In all such cases, service users must give a
significant reaction so as to fight for their right of accurate records.
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CONCLUSION
On the basis of above discussion, it has been concluded that health and social care sector
is a key sector responsible for providing care and medical protection to individuals aimed at
public welfare. Further, it has been analysed that there are various types of record keeping and
reporting guidelines and principles within health and social care sector that need to be followed
by organisations to make sure that they act as per the legislations stipulated by law. Besides this,
it has been comprehended that the non-compliance with any of the laws and legislations may
lead to enforcement or money penalty notices for care homes and may also bring bad name to the
entity. Also, it results in breach of fundamental standards set by laws for healthcare professionals
such as honesty, integrity, privacy, respect etc.
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REFERENCES
Books and Journals
Kotronoulas, G. and et. al., 2014. What is the value of the routine use of patient-reported
outcome measures toward improvement of patient outcomes, processes of care, and
health service outcomes in cancer care? A systematic review of controlled trials.
Journal of clinical oncology. 32(14). pp.1480-1510.
Coulter, A. and et. al., 2014. Collecting data on patient experience is not enough: they must be
used to improve care. Bmj. 348. p.g2225.
Bovaird, T., Briggs, I. and Willis, M., 2014. Strategic commissioning in the UK: service
improvement cycle or just going round in circles?. Local Government Studies. 40(4).
pp.533-559.
Aarons, G. and et. al., 2014. Collaboration, negotiation, and coalescence for interagency-
collaborative teams to scale-up evidence-based practice. Journal of Clinical Child &
Adolescent Psychology. 43(6). pp.915-928.
Newman, D. and et. al., 2015. Mental health service users' experiences of mental health care: an
integrative literature review. Journal of psychiatric and mental health nursing. 22(3).
pp.171-182.
Cameron, A. and et. al., 2014. Factors that promote and hinder joint and integrated working
between health and social care services: a review of research literature. Health & social
care in the community. 22(3). pp.225-233.
Greenhalgh, T. and et. al., 2016. Achieving research impact through co‐creation in community‐
based health services: literature review and case study. The Milbank Quarterly. 94(2).
pp.392-429.
Pecora, P. J., 2018. Evaluating family-based services. Routledge.
Donetto, S. and et. al., 2015. Experience-based co-design and healthcare improvement: realizing
participatory design in the public sector. The Design Journal. 18(2). pp.227-248.
Nelson, R. and Staggers, N., 2016. Health Informatics-E-Book: An Interprofessional Approach.
Elsevier Health Sciences.
Tambuyzer, E., Pieters, G. and Van Audenhove, C., 2014. Patient involvement in mental health
care: one size does not fit all. Health Expectations. 17(1). pp.138-150.
Online
What is the Freedom of Information Act?. 2019. [Online]. Available Through:
<https://ico.org.uk/for-organisations/guide-to-freedom-of-information/what-is-the-foi-
act/>.
Eight Data Protection Principles. 2013. [Online]. Available Through:
<http://hscnursing.co.uk/dataprotection.html>.
The fundamental standards and the CQC’s guidance on how to achieve them. 2019. [Online].
Available Through:<https://app.croneri.co.uk/feature-articles/fundamental-standards-
and-cqc-s-guidance-how-achieve-them?product=134>.
Record keeping: In-depth. 2019. [Online]. Available
Through:<https://app.croneri.co.uk/topics/record-keeping/indepth-0>.
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