Healthcare Record Keeping and Reporting

This report discusses the statutory requirements, regulatory bodies, process of storing records, reasons for sharing information, internal and external requirements, technology usage, and benefits of involving service users in healthcare record keeping and reporting.

HOW HEALTH CARE
SETTINGS RECORD
AND REPORT

Table of Contents
INTRODUCTION................................................................................................................................3
TASK 1 ................................................................................................................................................4
P1 Describe the statutory requirements for reporting and record keeping in own care setting.......4
P2 Describe regulatory and inspecting bodies requirements for reporting and record keeping in
care setting.......................................................................................................................................5
TASK 2 ................................................................................................................................................5
P3 Describe process of storing of records in own care setting .......................................................5
P4 Explain the reasons for sharing information within own setting and with external bodies........6
P5 Accurately illustrate the internal & external requirements for recording information in own
care setting.......................................................................................................................................7
TASK 3 ................................................................................................................................................8
P6 Describe how technology is used in recording and reporting in own care setting.....................8
P7 Explain the benefits of involving service users in record keeping processes.............................9
TASK 4...............................................................................................................................................10
P8 Produce accurate, legible, concise and coherent records regarding service user care for
different service users following own setting’s guidelines............................................................10
P9 Explain different aspects of own management of service user records with reference to
compliance with national and local policies and guidelines..........................................................10
CONCLUSION..................................................................................................................................12
REFERENCES...................................................................................................................................13
Books & Journal:...........................................................................................................................13

INTRODUCTION
Healthcare sector is changing drastically and which it is important to keep the data as well as
information safe of each and every patient. Many methods are being used by healthcare and
hospitals to keep matters and data confidential. London Bridge hospital, which is a private hospital,
headquartered in UK. Record keeping is defined as maintaining as well as managing accounts,
profile, credentials of individual as confidential for future use. This report includes requirements for
report and record keeping, regulatory and inspecting bodies, process of storing records, reason for
sharing information, internal & external requirements for record information, technology usage,
benefits of involving service users, produce accurate records regarding service user care and
different aspects of own management of service user records.
TASK 1
P1 Describe the statutory requirements for reporting and record keeping in own care setting
Statutory requirements are important which are to be maintained by every organisation in
proper manner so that problems and issues do not arise in near future. In healthcare industries it has
become crucial and has been approved as well as enacted by government to make ensure that every
hospitals follow inherit those requirements in their services. In relation with London Bridge
hospital, they are aware about their roles and responsibilities. It is essential for them to keep record
as well as report in their management and as professional it is crucial to analyse such information
carefully. The legislature, executives and judiciary plays vital role in setting the legal as well
policies for health & social care practitioners (Nasaruddin, 2018).
Judiciary- These provide the forum or guidelines for development of health policies.
Judiciaries are mostly appointed by political authorities and also they are appointed because they
are able to make decisions effectively in context to both the party.
Legislature- Further comes for development of government health policy is legislature. If
any case Judiciary fails in making decision regarding the rules as well as regulations then it comes
to legislature. These are responsible for promoting and protecting public health and make ensure
that every healthcare system work under government consideration ( Kingsman, 2017)
The executive- The executives are set by government which are able to manage health
policy formation in healthcare. Moreover as the head or person with senior post in this section have
the power to take major decisions regarding health and safety procedures.
Thus, the above matter states that statutory requirements are necessary as well as adopted

by every healthcare system with appropriate measures and decisions are being taken under policies
formulated & regulated by legislature, executive and judiciary. This crucial as assist organisation to
run their functions & operations in smooth as well as effective manner. So, it is duty of authorities
to ensure that management follows all the policies with effective decision making.
P2 Describe regulatory and inspecting bodies requirements for reporting and record keeping in care
setting
In health care sector, it is mandatory to focus on keep record and report all the paperwork
through physically and digitally as well. Mostly in healthcare, staffs maintains paperwork for using
information of patients because it became easy for them to collect as well as store. In relation with
London Bridge Hospital, they make ensures that such inspecting bodies are being undertaken in
proper manner so that problems do not occur. As regulatory and inspecting bodies, they are
responsible for managing all policy and procedures. Care providers are also present in this process
so that documents, credentials which are being stored are well organised with proper attention.
Thus, the bodies which are involved are described below-
Employers- In this, care provider must examined they are they are registered under
government rules & regulation to regulate policies and procedures in hospitals in effective manner.
Further it is also needed to examine that they are comply with data protection & also do have access
to record legislation. Then, service users are to effectively planned and well organised so that
information is being used efficiently. Moreover, they also need to analyse that staff record &
patient’s data are up to date and updated on their system as well as paperwork (Benwell, 2017).
CQC Standards Compliance
Under this, HASA (health and social act) analyse that regulation covers record keeping
essentials under Regulation 17.
Through this, record is to be kept with proper care with complete detailed information of
service user so that monitoring done appropriately (Manogaran, 2017)
Then, it also should keep its eye on person who is managing all the regulated activities in hospital.
After a brief analysis of above paragraph, it is analysed that regulatory and inspecting bodies
are being considered as crucial part of healthcare industries. Thus, CQC standards compliance are
being considered by selected hospital for achieving goals as well as objectives in proper manner.

TASK 2
P3 Describe process of storing of records in own care setting
Record keeping is useful in every sector for backup, competition etc. Also, with help of
book keeping it to be examined that patient feel secure when it comes to collecting of data of their
problems. A good record keeping in healthcare results in team work or say development of quality
of healthcare which is then used in effective manner. Also, it is time consuming procedure but is to
be used in appropriate manner. In relevance with The London Bridge Hospital, handle as well as
manages both record & report of patient data so that it is not misused by any other third party or
does not go in wrong hand. There are several type of health care which are mentioned below-
 In hospitals, hand written, computer based or both are adopted by entity for keeping and
storing the record keeping as well as report accurately.
 Then, those verified as well as checked by staff individually so that wrong data is not stored
in system (Shahrul Asari, 2017).
 There are many nurses or peons who left the important papers so it is needed to be make
sure those patients papers are not to be left outside or at public places because it is unethical
behaviour.
 Furthermore, when keeping such records updated systems are to be acquired by
organisation so that they do not get lost or trashed. In relevance with The London Bridge,
their IT department are skilled and knowledgeable which assures that new and latest
software as well as hardware are used in every system of hospital (Vincent, 2019).
Elements of patient’s records are-
Handover sheets, letters, assessment forms, forum, medical records, charts & graphs,
discharge as well as transfer list of every patient and many more. These are some of the components
which are important to be kept with good care and eyesight. Main advantage of record keeping is
that some legal issues are involved in keeping records so by proper consideration they are handled
in effective manner.
So, after examining the above matter, it is stated that all process of storing record keeping is
not easy task and requires proper monitoring accurate results. Also, for development of healthcare
services, record keeping and report are the source through which they can implement strategies and
tactics for their business.

P4 Explain the reasons for sharing information within own setting and with external bodies
When data and credentials are collected as well as gathered by care practitioners they are to
be shared within the management with staff senior authorities etc. Information is shard because in
healthcare sector, it is necessary so that a deep knowledge of patient problem is known and care is
taken accordingly. In relevance with The London Bridge, they are aware that it is used for good
purpose by every individual which has the record keeping data. Main reason why credentials are
shared is that it becomes easy for healthcare authorities to take actions and decision based on
gathered information (Zhou, 2019).
There are various rules while sharing information are to be kept in mind and are discussed below-
When sharing data of patient, it is crucial to have proper knowledge of data protection act
and human rights so that it is done in right way without breaking nay rules or regulations.
Then, honesty is to be placed at priority level because data is shared one need to be honest to
the patient that with whom, why, the credentials are used. This makes both parties relaxed and
develop a trust as well as mutual relationship which is helpful in future prospect.
Also, when sharing data, keep records as well as report that it is being actually shared & need to
have accurate records so that issues do not arise in future.
After analysing the above paragraph, it is seen that sharing information is not bad thing but
when it is done proper measures as well as regular updating is to be given to senior authorities. By
doing this, care practitioner is able to make decisions in effective way. So, the above mentioned
rules should be adopted so that errors or conflicts do not occur in process (Prashanth, 2019).
P5 Accurately illustrate the internal & external requirements for recording information in own care
setting
In healthcare sector, there are various types of requirements which are needed by hospitals
for their proper functioning as well as operations. In context to The London Bridge Hospital,
internal & external requirements are being managed and maintained by HR or senior staff with
accurate list so that minimum manpower is used in finding those requirements. Furthermore,
internal record is crucial for management of hospital such financial position, earlier health check-
ups etc. Also, sometimes internal records are to be carefully recorded because they can be misused
by anyone. Thus, these are much more prompt and factual and such records are used for care as well
as treatment when there is actual need of such requirements.
Whereas external requirements for recording information is also very necessary so that
injury or disease of every patient is natural or man-made so that it is becomes easy to manage

problems and process appropriately. By this improvement is needed in quality when record keeping
is done. Such improvements are mentioned below-\
Improvements in quality of record keeping-
 Make sure that records are complete, well organised, secured as well as updated with clear
visibility so that it does not violates the terms and condition of DNAR agreements or
medical policies.
 Prepare and acquire record of doctor or any family or friend visit to the patient.
 Do investigate with authorities regarding prescription of patient is wright or wrong, and if
patient need home care then all the basic requirement are to be provided with agreement.
(Badnjević, 2020).
TASK 3
P6 Describe how technology is used in recording and reporting in own care setting
Today's environment is continuously changing where there are number of technological changes
within the healthcare sector. The one of these changes is digitalization of recording and reporting
concept. There are various tools which help health care organisation in digitalizing recording and
reporting function within the society. There are some uses which are mentioned below:
Great patient care: the major use of technology is to increase the patient care within
organization. It will help London bridge hospital in automatically alerting the meaning physician to
the potential issues like allergy or intolerance of certain medicines. This also helps organization in
accessing from the nearby medical facilities which will help doctor as well as patient in analyzing
the situation effectively (Pinfold, 2019).
Improve public health: the main use of technology within the healthcare industry is to
improve the public health for this there are number of software which provide the evaluation of data
to clinical research and helping in advancement of medical knowledge and the development of
treatment for the common health problem. Help company maintaining the standard health it system
which will provide the widespread outbreak and help company in enabling some preventive
measures.
Better and safer data storage: bringing new technology within the healthcare industry will
also help in increasing and saving the data storage. There are cloud computer technologies which
allow the organization for masters of information to be stored at unbelievable low cost. This is all
with without any limitation and low expenses buy some additional hardware services.it also help in

increasing the reliance on the system and new technology which provide the cloud storage product
again the low cost of sensitive data with strong backup and recovery services.
Centralized data point: today’s also important part of the healthcare industry as it provides
a centralized data point for every organization which is related to healthcare. While having a central
point for that all data information is extremely useful, over dependence may result in serious
problems for the connectivity and will also increase the bandwidth problem. This is solved by the
breaking of new technology where it to the data in the cloud computing technology which also
increase the mobile use of security and data protection.
P7 Explain the benefits of involving service users in record keeping processes
There are number of benefits while can be drive by a healthcare firm by the involvement.
Service user is someone who is receiving the services or using the services on a primary or
secondary mental health care. This term is used to refer those individuals who use the mental
services regarding their health and more concerned with the service reform and improve then with
radical changes (Greer, 2019).
It is important for organisation to involve the service users within the record keeping process
this is because they are the prime user of this record keeping process as they use regular services of
organisation with for their treatment. They are also issues with their mental health so organisation
have to keep the record digitally which will help them in guiding and taking medicines and other
prescribed drugs in a proper manner.
 The first benefit which can be drive by the service user within the organisation for records
keeping process is that they can easily identify their prescribed drugs in a fixed process.
Because of their mental illness and treatment a regular illness of emission can arise in such type
of patients, if there is use of technology within the bookkeeping system. Then this type of
patient will get the help in identification of their prescribed drugs without omission (Teixeira,
2019)
 It is also beneficial in their treatment because they are the regular visitors within the
healthcare organisation. These type of system will take care of these patients as it record the
entry and exit times of this customer which will directly related to their safety and security.
 This type of software and artificial intelligence will also help these patients as it guide the
doctors and medical practitioners within the organisation about the critical and normal
condition of different patients which are directly related to mental health. Where it can also
identify their behaviour and use their identity for their treatment.

 it is also beneficial as it proper record of these type of patients and their complexities which
guide the doctors and other staff of the organisation about the key consideration which must be
made before starting the treatment or any serious operation of these type of customers or
patients.
 it also help the doctors and other drugs for management of the time period and process of these
clients where it can help them in guiding and allocating a proper time to some special
treatments and therapies which are directly related to the regular users within the healthcare
industry.(Budrionis, 2020).
TASK 4
P8 Produce accurate, legible, concise and coherent records regarding service user care for different
service users following own setting’s guidelines
Every individual has a right to get the adequate treatment of his heart disease as well as
India at the proper and adequate records. Now the health care sector is continuously developing
where we can start using audio video and digital records for proper bookkeeping of data related to
treatment of patients. There must consideration of approaches which for recording and using the
data. This is Accurate and Concise, up to date, reliance, easy to understand by the service user.
There are continuously increase cases of improper bookkeeping system within the healthcare
industry which is impacting adversely on the patient treatment. There is accurate legible organised
and current record regarding the service users here for different services user. This is produce to
provide the assistance to the employees in following ways:
 Provided documentary evidence to the authority which is involved in the treatment of service
user (Nasaruddin, 2018).
 It also provide information to assist with the analysis and care planning of an individual
 The documenting service also provide individual service user
 It is also from to aloud the continue statement of the patient even the charge officer is on
leave.
 It also helpful in supervision and development of other treatment methods which must be
suitable for or treatment of patient who are service user
There are number of policies and procedures which are form for this. The major policy is that all
record must be finalized within the three working days treatment of the respected patient. There is
also a condition that some cases are bounded by a specific timeline special cases must be given

some extra time limit for their record. These are the policies which are form for every type of
service loses of the healthcare industry where they can access easily to the specific treatment and
the main case of regarding protocol must be followed.
P9 Explain different aspects of own management of service user records with reference to
compliance with national and local policies and guidelines
There are various tools and techniques which are used within the recording system. In the
above mentioned service user records there are number of things which are considered while
formation of this there is consideration of some principles which are directly related to bring
effectiveness within this function. Some of these principles are mentioned below:
Accuracy: accuracy is the most focused thing within all the functioning of the above record
management. Entries must be accurate and must be distinguish between the fact opinions
assessments judgement and decision where recording must distinguish between the first and
information and information obtained from third parties ( Kingsman, 2017).
Clarity: recording should be clear and chronological entered. The reader should not be left
with and interpretation of recording that differed from the author's meaning of the meaning which is
conveyed by the information sender.
Responsibility: the management of the information is about the service users is the
responsibility of all the employees within the health care services. The regular practitioners are
primary involved those type of person who directly of and witness the events that is being recorded
and those who has participated in the meetings in conversations for completing the records.
(Benwell, 2017).
Anti-discriminatory practices : it is also ensure within the all management records the
record must be demonstrated on anti dis criminative perspective and must not include any
derogatory comment by the author are the prescription related to race culture gender age religion
language communication and other disability faced by the the patient or client who is also irregular
user of hospital
Service user involvement: entries will be reflected that the view of every service user
within the hospital must have been actively short and fully recorded. All so that they can contribute
their comments where they are agreeing or disagree from the professional opinion and the treatment
which are they using. This all things must be recorded for evaluation and feedback mechanism
within the organisation.
The care must be taken with the recording to ensure the confidentiality and the principles

with the data protection act 1998, these all are considered while forming the management plan
within organisation where confidentiality can be maintained for saving the interest of both service
customers and organisation (Manogaran, 2017).
CONCLUSION
From the above study, it has been concluded that health sector is gaining growth rapidly in an
effective manner. In addition to this, it is important for health to maintain a record of all its patients
so that it is easy to get information in future or the past history of patients. There are various tools
used by the health sector in order to record information. Moreover, it is essential for an organisation
dealing in health sector to follow all the laws and legislation as it help in smoothly function out all
the activities in an appropriate and effective manner. One of the factor that plays an important role
is technology. The technology help to save information in a systematic manner along with this, it
save down the cost of an organisation. But, it also has negative impact on the performance as it
changes rapidly and in order to gain success, it is essential for an entity to cope up with this and
make use of advanced technology. The companies follow the process of recording in order to
develop it in a systematic and effective manner. There are different local as well as national policies
in this sector that is require to follow in order to smoothly and systematically carry out activities.

CONCLUSION

REFERENCES
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