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.