Healthcare Record Keeping and Compliance

This assignment delves into the critical aspects of healthcare record keeping, emphasizing the need for compliance and accurate documentation. It highlights the use of technology to authenticate and manage patient records, both internally and externally. The report examines the structure of maintaining records and reports in Ramsay health care homes, as well as the technology used to identify proper and authenticated records and reports of customers and patients. Relevant case studies and research papers are referenced to provide evidence-based information on addressing electronic health record data challenges for quality improvement.

HOW HEALTHCARE
SETTINGS RECORD AND
REPORT

Table of Contents
INTRODUCTION...........................................................................................................................1
LO 1 ................................................................................................................................................1
P 1 Statutory requirement for reporting and record keeping in Ramsay health care settings.....1
P 2 Regulatory and inspecting bodies requirement for reporting and record keeping in Ramsay
health care settings. ....................................................................................................................2
LO 2 ................................................................................................................................................3
P 3 Process of storing the record in Ramsay health care settings...............................................3
P 4 Reasons for sharing information within own settings and with external bodies..................4
P 5 Illustrating the internal and external requirements for recording information in Ramsay
health care settings......................................................................................................................4
LO 3.................................................................................................................................................5
P 6 Technology use in recording and reporting in own care setting...........................................5
P 7 Benefits of involving service users in record keeping processes.........................................6
LO 4.................................................................................................................................................7
P 8 Producing coherent records regarding different service users..............................................7
P 9 Different aspects of own management of service user’s records with reference to
compliance with organisational and other relevant polices........................................................7
CONCLUSION................................................................................................................................9
REFERENCES..............................................................................................................................10

INTRODUCTION
Health care homes are the important aspects for customers life as they give light to
customers life and make them strong to face the challenges which they are fighting with their
routine work. Heath care homes are established to give new life to patient and also record their
data's and medical issue which helps doctors to take feedback in near future and present their test
report which helps them to improve their condition. Record plays the role of evidence in court
cases and also helps social media to discuss the hospital polices and norms of treating their
patient. Present report is based on Ramsay health care home which is based on UK. It was
founded on 23 November 2007 by Paul Ramsay who is an Australian business man and
established his parent company in Sydney as well.
Report will include the statutory requirements of keeping record and reports in the home
care settings and also include the regulatory and inspecting of books and records in the company.
This report also includes the process of storing the records. It explains the reason for sharing the
information with external bodies. Further it describes the requirement for internal and external
requirement for recording the information. It also explains the technology used in recording and
reporting the heath care homes. Lastly it explains the analysis and process of maintaining records
and identifying the potential and actual difficulties arise in Ramsay heath care settings.
LO 1
P 1 Statutory requirement for reporting and record keeping in Ramsay health care settings
Statutory requirement means that rules and regulation which are passed by the central and
state government which means the norms which are specially designed for the heath care to
follow the laws made buy the government of the UK. Its statutory requirements for reporting in
Ramsay health care setting are(Ramsay Heath care, 2019).
~ They have to maintain a proper report of their employees working in the premises as a full-
time employer and have to keep their health and safety report also which helps them to identify
the problem when any of the employee feeling unconscious in work timings(MacLaren and et.al.,
2018).
~ Heath care hospital had to maintain a proper report of their patient so that when they refer to
new hospital they can take proper care of them through their report and understand the medical
health and issues.
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~ Ramsay health care maintain proper and authentic report and record so that when any patient
want to read the report they can clearly identify their problems and medicines mentioned on that
report(Gray and et.al., 2016).
~ Record plays the role of evidence, so hospital maintains a proper record so that patients or
client can easily demand their record when they lost the original one.
~ Major point that take care in report and record is that nothing such mention in the report Nd
record which insults and make fun of the patient regarding their medical problem or their
personal life.
P 2 Regulatory and inspecting bodies requirement for reporting and record keeping in Ramsay
health care settings.
Heath care records are the documents which helps the patient to properly analyse their
problem and also can take suggestion from different team member regarding their medical report
and health and safety issues. The regulators and team head department of the Ramsay heath care
regulates and inspect the books and other record so that when patient demand any reports, they
can easily present them within the allotted time(Rodriguez and et.al., 2016).
It's the duty of the Ramsay heath care to inspect the books and records of the hospital so
that they can take fair and clear decision regarding the management team and also provide true
guidance to their clients who are dealing with them in the present or in near future. In medical
field to inspect the records and other documents are strictly regulated by the medical team so that
if courts demand any evidence, hospitals are fully liable to present it and are not overwritten and
language is also properly authenticated.
It Is the regulatory authority of the hospital to provide proper heath care and other
medical benefits to the aged people and person who are mentally and physically challenged so
that society accepts them with warm heart and also hospital treats them with proper and efficient
care(Ramsay and et.al., 2019).
M 1
Results for not following the government norms bring lot of consequence in smooth
working in heath care as if Ramsay health care didn't follow the government laws they are bound
by lot of penalties and fine, Violation of any polices relating to inspecting of books and records,
regulating the government polices and also some policies designed by health care and if they are
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not followed by junior employees than legal punishments are imposed with fines(Melnychuk and
et.al., 2018).
D 1
If employers of the Ramsay heath care share any of the information which is confidential
and violates any rules of the company by sharing any internal data of the company in the social
media it violets the rules of the law which result in serious consequences as it may result to civil
crime and this may affect the job security of the employees and any other person who disclosed
the hospital information(Record Keeping and documentation, 2019).
D 2
Ramsay health care arrange a proper area to get reviews regarding their heath care and
services which they are offering in the way of feedback of hospital heath care. They can get the
review or implement this procedure through feedback form and in that form they can raise
various question regarding the environment of the hospital, doctors treatment and behaviour,
employees satisfaction level, facility and many more which helps Ramsay hospital to improve
and innovate their services(Garland and et.al., 2018).
LO 2
P 3 Process of storing the record in Ramsay health care settings
Medical records of the patients in the Ramsay health care are their priority documents
which should be kept even they are discharged from the hospital. Patient discuss their medical
problems with the hospitals in believe that they keep it confidential and didn't discuss with
anyone without their information or having the written consent. The records are kept in three
from whether it can be written on paper or by electronic form or by both method. NHS(National
health care system) implement the rule that every hospital had to maintain proper records and
assist information to secured the data under the data protection Act. After analysing the report
made than sort the data ion the bases of caste, sex, region, religion and health issue(Hemler and
et.al., 2018). Patient are divided according to that and that put all the records either on electronic
form or by documents form in proper place so that they can be checked by that person who are
specially assigned to mange it and check it.
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The holder of that duties are truly responsible for the safety of the documents because the
documents can be demanded at any time by patient, or clients or even court order to present the
documents in case of evidence to help them to solve the case(Record Keeping and
documentation, 2019).
P 4 Reasons for sharing information within own settings and with external bodies
Sharing information with external bodies are sometimes results in improvement of patient
life and medical health. As doctors take the consent to share the information so that they can get
the proper way or authority to improve the heath of the patient and also analysis the problem
which the patient is facing(Martin, Gasoyan and Wierz, 2019). If the reports are exchanging by
way of electronic form that it the duty of doctors, nurses and pharmacists to maintain the rules of
non disclosure of their medical report without the person consent. The major reason behind
sharing the medical report and record inside the Ramsay health care is that they can discuss the
patient problem internally and rectify it by taking help from each other. As Ramsay is the biggest
health care hospital which shows that best doctors are engaged with these services and they treat
the patient with loyalty and respect and also maintain the positive thought to make the patient fit
and strong to beat their health issue(Holtrop and et.al., 2016).
Usually doctors take help from outsiders so that they can rectify the problem and solve it
in different way. They mainly use NHS number which is given to patient to identify the patienter
and their problems to improve the care provided to them with proper health and safety
norms(Record Keeping and documentation, 2019). These type of services helps the patient to
grow more confidence for their improvement and also improve the reputation of the Ramsay
health care hospital. The reason behind sharing the details is also that if person can't afford the
expense of the hospital they can refer to some other where they can be treated equally important
but with low expenditure(Gray and et.al., 2016).
P 5 Illustrating the internal and external requirements for recording information in Ramsay
health care settings
Internal requirements which the Ramsay health care follows is regarding to procedure or
instructing which they assigned to employees to follow the procedure and perform the duties
accordingly. This means that records which originated in company internal matters like relating
to patient health equipments used, their expenses relating to treatment or any other test which the
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doctors order to be done by that patient are covered under the internal process. The things which
are recorded internally such as patient discharge details, medical report of the patient and
recommendation done by any doctors regarding their health issues and other expense incurred in
the heath care(Price and et.al., 2017).
External requirement for recording information in Ramsay health care is that when any
patient is admitted in hospital they show the reports of their test and according they are admitted
in hospital and proper treatment are started according to their medical health and issue. The
information are recorded on the bases of customers who admitted in hospital and their records
are maintained on the bases of external reviews and reports which they presented in
hospital(MacLaren and et.al., 2018).
M 2
Ramsay heath care uses the electronic way to keep and maintained their records of their
patient and sort according to the health issue like if any person is suffering from mental health
care they are recorded in that department as all the record are managed in the single room but
they sorted according to the department with NHS number so that they can be clearly identified
when they demand the records of their report(Record Keeping and documentation, 2019).
LO 3
P 6 Technology use in recording and reporting in own care setting
Nowadays technology has helped in every aspect of life and have a widespread criteria,
likewise there is an immense change in the recording of data in the hospitals and health care
service providers. There are various use of technology in the recording of the patient's data,
disease related and the treatment given to the patient in this regard in Ramsay Health Care
Home. It includes test reports, X- Ray and other vital information(Rodriguez and et.al., 2016).
Earlier the data of the patients are to be recorded on the paper but now technology have made it
easy and data is generally recorded in the hospitals, clinics and private practices in the databases
on computers. The data so recorded is easily accessible and reliable as there are less chances of
errors in the recording of the data. Also, it complies all the related data of a specific person in
one place. It can help in effectively managing the data thereby increasing health care delivery,
patient safety and also improves the relationship between the patient and Ramsay Health Care
Home(Gray and et.al., 2016).
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P 7 Benefits of involving service users in record keeping processes
Record keeping process in the healthcare providers is an important process. There can be
involvement of the service users that are patients in the Ram Say Healthcare Home. The benefits
of involving service users in record keeping processes are improvement of health and well being
of patients as involving them in record keeping helps the patient to choose the best treatment
according to there need and potential creating patients satisfaction. When the patients are
satisfied about the treatment and facilities so provided in Ramsay Healthcare Home they
complain less about the services which increases the quality of the organization and the trust on
the treatment providers(Consequences of Non Compliance, 2019). Also, there is a transparency
in the healthcare home. Patient choose the plans and treatment which includes check ups on the
daily basis which are evaluated by them according to there financial position and backgrounds.
There is an efficient allocation of resources of Ramsay Healthcare Home by providing the
required services to the patients and no unnecessary treatment to them. Also in some countries
the involvement of service users in record keeping processes are legal requirement(Record
Keeping and documentation, 2019).
M 3
Use of digital technology in medical management procedures are very helpful as they
provide the clear, easy accessible and prominent data about the patient in Ramsay Healthcare
Home. Technology is being used by doing routine check ups, tests of patients and the keeping of
records by them in the organised and systematic forms. Digital technology also helps the patient
and doctors to found the patient data at later date when needed by them. There are much
equipment and machinery available in the hospital which helps in proper treatment of the
patients in Ramsay Health Care Home(Ramsay Heath care, 2019).
D 3
Through the use of technology the patients are highly benefited in Ramsay Healthcare
Home as it involves the use of various equipment and health care products in there normal daily
regime like there are equipment to check the blood pressure level, sugar level in the patient
which can be checked by the patients at personal level too. Through the involvement of service
users in the management of records the patient are well aware of the treatment provided to them
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by whom and at what cost, also it records patients medical history which help in proper treatment
by doctors(Consequences of Non Compliance, 2019).
LO 4
P 8 Producing coherent records regarding different service users
It is essential for Ramsay care home that to maintain record in legal and concise manner.
Ramsay deals with different service users such as patients those who are suffering from
dangerous illness, common patients suffering from normal diseases such as cold etc., metal
patients, regular users etc.
Hand written record keeping system
In accidents or sudden emergency cases hand written record keeping system is prepared.
In this, professionals or administrative staff add all the details such as medical history, age,
name, time of visiting hospital etc. in register. Staff ensures involving up to date information of
users(Ramsay and et.al., 2019).
Computer based system
Electronic record system is maintained in the Ramsay hospital. It is done for the people
those who are taking treatment from hospital from longer duration. Administrative staff add
medical history, medication charts, discharge details, patient assessment form in computer.
Combination of both methods
Many times Ramsay uses both these methods of record keeping, once user has taken
services of the hospital then this record is added into computer as well. This helps in maintaining
long term data(Melnychuk and et.al., 2018).
All the time care home follow the principles of good record keeping as all the details are
factual, consistent and actual. In this, condition of service users is written and all entries are
done including sign and date of service user or its family members. Ramsay hospital take care of
avoiding meaningless phrases and do not involve any kind of offensive subjective statements.
P 9 Different aspects of own management of service user’s records with reference to compliance
with organisational and other relevant polices
Record keeping can be defined as essential tool that helps in improving care process in
hospitals(Garland and et.al., 2018). Once patient visit the care home, staff make records as soon
as possible. By this way, it becomes easier for medical professionals that to provide accurate care
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to patients. This type of record keeping system is helpful in promoting good communication and
addressing needs of service users. Ramsay care home always add relevant information such as
demographic situation of user, reason of visiting hospital, diagnoses, written instructions,
medication etc(Ramsay Heath care, 2019).
Ramsay hospital follows CQC standards. Health and social care act 2008 (under 17
regulations) explains requirements of good record keeping. This legal framework is followed by
the care home and it ensures maintaining accurate and complete information of user.
Furthermore, as per the guidelines of CQC hospital keep their personal information secure and
confidential(Consequences of Non Compliance, 2019).
Every year Ramsay hospital conducts audit in order to achieve CQC compliance with
regulation 17. It ensures that treatment which is provided to patient is accurate and fit for the
purpose. Managers continuously monitor the record and review records time to time in order to
minimise complains. Welsh standard compliances explains that hospitals required to maintain up
to date information and have to follow data protection act 1998 carefully. All these things are
managed and followed by the Ramsay hospital sensibly, Data is recorded in password protected
computer and no service provides discuss personal detail of patients with other user(Hemler and
et.al., 2018).
M 4
Once patients visit the hospital then it is essential for the care home to maintain their
records. Administrative staff has to add personal, demographic situation of person, medical
history, issues etc. in records. If record keeping is poor then it may affect care process and health
care professionals fails to understand the issue of user. There are so many deficiencies in record
keeping such as absence of clarity, Inaccuracies, missing information etc. Potential difficulties
are such as user fails to explain the actual health issue, spelling problem, poor record related to
medical history etc(Martin, Gasoyan and Wierz, 2019).
D 4
Ramsay hospital follows all the ethical and legal principles in order to maintain accurate
records. This is very effective in order to provide timely care to the service users. This is helpful
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in improving accountability and early detection of problem. Goof record keeping system allows
health care professional in taking right decision and minimising health risk(Consequences of Non
Compliance, 2019).
CONCLUSION
From the above study it can be conclude that records and report are important part in
heath care homes as in the absence of these document's hospital can't crack the actual problem
and didn't recognise the issues happens with the patient. As patients are treated according to the
records maintained and doctors also analysed them according to the reports. This report includes
the structure of maintaining records and reports of the Ramsay health care homes and also the
technology which they used to identify the proper and authenticated records and reports of the
customers and patients whether internally and externally.
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REFERENCES
Books and journals
Garland, A. and et.al., 2018. Reassessing access to intensive care using an estimate of the
population incidence of critical illness. Critical Care. 22(1). p.208.
Gray, C.S. and et.al., 2016. Supporting goal-oriented primary health care for seniors with
complex care needs using mobile technology: evaluation and implementation of the health
system performance research network, Bridgepoint electronic patient reported outcome
tool. JMIR research protocols. 5(2).
Hemler, J.R. and et.al., 2018. Practice facilitator strategies for addressing electronic health record
data challenges for quality improvement: EvidenceNOW. The Journal of the American
Board of Family Medicine. 31(3). pp.398-409.
Holtrop, J.S. and et.al., 2016. Effect of care management program structure on implementation: a
normalization process theory analysis. BMC health services research. 16(1). p.386.
MacLaren, J. and et.al., 2018. A qualitative study of experiences of health and social care in
home mechanical ventilation. Nursing Open.
Martin, T.R., Gasoyan, H. and Wierz, D.J., 2019. A Framework for Contracted Health IT
Performance Assessments. Hospital topics. pp.1-8.
Melnychuk, M. and et.al., 2018. Centralising specialist cancer surgery services in England:
survey of factors that matter to patients and carers and health professionals. BMC
cancer. 18(1). p.226.
Price, K. and et.al., 2017. Education and process change to improve skin health in a residential
aged care facility. International wound journal. 14(6). pp.1140-1147.
Ramsay, N. and et.al., 2019. Health Care While Homeless: Barriers, Facilitators, and the Lived
Experiences of Homeless Individuals Accessing Health Care in a Canadian Regional
Municipality. Qualitative health research. p.1049732319829434.
Rodriguez, H.P. and et.al., 2016. Increased use of care management processes and expanded
health information technology functions by practice ownership and Medicaid
revenue. Medical Care Research and Review. 73(3). pp.308-328.
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Online
Consequences of Non Compliance.2019.[Online].Available
through<https://www.kent.edu/ucm/social/consequences-noncompliance>
Ramsay Heath care.2019.[Online].Available through<https://www.ramsayhealth.co.uk/>
Record Keeping and documentation.2019.[Online].Available
through<https://www.ausmed.com/cpd/articles/record-keeping-documentation>
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