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Effective Reporting and Record-keeping in Health and Social Care Services

   

Added on  2021-01-02

13 Pages4175 Words454 Views
HOW HEALTHCARE SETTINGSRECORD AND REPORT

TABLE OF CONTENTSINTRODUCTION...........................................................................................................................1LO 1.................................................................................................................................................1P1. Statutory requirements for reporting and record keeping in own care setting......................1P2. Regulatory and inspecting bodies requirements for reporting and record keeping in a caresetting...........................................................................................................................................1M1. Consequences of non compliance with reference to the media, service user safety and thecredibility of the care setting........................................................................................................2D2. Recommendations for improvement.....................................................................................2LO 2.................................................................................................................................................2P3. Description of Records storing .............................................................................................2P4. Reasons for sharing information within own setting ans with external bodies.....................2P5. Illustrations on internal and external requirements for recording information......................2M2. Current processes related to storing and sharing records.....................................................2D1. Consequences of non compliance with media, service user, safety and credibility of thecare setting...................................................................................................................................2D2. Recommendations for improvement.....................................................................................2LO3..................................................................................................................................................2P6. Use of technology in recording and reporting.......................................................................2P7. Benefits of involving service users in record keeping processes..........................................3M3. Use of digital technology in relation to own medical management procedures or care plan......................................................................................................................................................3D3. Effectiveness of use of technology ensuring appropriate care and maintainingconfidentiality..............................................................................................................................3LO 4.................................................................................................................................................3P8. Produce accurate, reliable records of data for different service users...................................3P9. Different aspects of own management records......................................................................4M4. Process of maintaining records for identifying any actual difficulties.................................4D4. Effectiveness of own completion of documentation to ensure appropriate care andeffective reporting........................................................................................................................4CONCLUSION................................................................................................................................5REFERENCES................................................................................................................................6

INTRODUCTIONHealth and social care is vital component of an individual's life to maintain the qualityand delivery of services. It has highlighted the need to promote the effective reporting as well asrecord keeping for avoiding any delays or mis management of the information. This isconsidered as important when providing assistance by the professionals working for thebetterment of the patients. This assignment consists of understanding the various aspects inaccordance with implementation of the record keeping and reporting. This includesunderstanding the statutory requirements, use of technological tools, stages of record storage,accurate and reliable records of data for different service users and others. Herein, theInternational Hospitals Group has been considered which is headquartered at Denham,Buckinghamshire and is active in services like medical equipping, healthcare consultancy anddesign etc. This organization is focusing on bringing confidentiality and using a robustframework for the entire safety of the people involved, which has been examined in systematicorderLO 1P1. Statutory requirements for reporting and record keeping in own care settingInternational Hospitals Group must adhere to the legislation and the statutory guidancefor proper implementation of record keeping and reporting. There are several guidelines whichhas been laid out for smooth running of operational activities by the professionals. General Data Protection Regulations, 2018: This is the primary law for regulating thecompanies for preventing the citizens' personal data. Moreover, GDPR contains severalregulations, policies and protections and mostly designed to safeguard the rights and the personalinformation of the individuals (Hanauer and et.al., 2015).Human Rights, 1998: This act emphasize on the human rights mentioned under the EuropeanConvention on Human Rights. For instance, Article 8 shed light on the right to respect for thefamily and the private life and Article 5 infers right to personal liberty. Thus, it means a set ofrights which is entitled to all the citizens of the United Kingdom.Information Commissioner's Office Data Sharing code of practice (ICO, 2016): This is one ofthe statutory guidance which comes under the Sections 52A and 52D of the Data Protection Act1998. It conducts consultation in regard to the proposed Code and is designed to impose theadditional legal obligations. There are 12 sections such as Data sharing and The Law,governance, Fairness, transparency and consent etc. which is adopted to maintain the standardsof work ethics by professional bodies and individuals as well.P2. Regulatory and inspecting bodies requirements for reporting and record keeping in a caresettingThere are several requirements outlined by inspecting and regulatory bodies that arenecessary for reporting and record keeping at International Hospitals Group. These have laid thestandards and code of ethics for proper functionalities of the professional practices for the qualityand delivery of services. Thus, clinical record keeping is essential in maintaining the patients'care and support. CQC (Care Quality Commission) has framed the new fundamental standardsfor easy transitional inspection composition. There are eleven proposed standards of CQC toprovide safety, effectiveness, care, responsiveness and well-led leadership and governance tomaintain the record keeping and reporting (Greenbaum, Dodd and McCracken, 2018). This issignificant for rigorous review and updation in terms of the existing policies and the reinforcedoutcomes to provide the information.1

In regard to its failure while implementation part, there are damaging effects on theprofessional credibility attached with professionals, loss of privacy, or respect and dignity of theservice users and the practitioners etc. of the chosen organization. Moreover, the ineffectiveauditing leads to monetary penalty notices or contract termination in relation to the breaching orprivacy violation in the future when the authentic checking gets initiated. The media responsesare also helpful in streamlining the unethical practices or any other illegal activity formaintaining the reporting and record keeping of IHG.M1. Consequences of non compliance with reference to the media, service user safety and thecredibility of the care settingConsequences are adverse in terms of maintaining the safety and the credibility attachedwith the IHG. The no compliance policy only paves the path of inefficiency and completeincompetency of the professionals including the staff, personnel, practitioners, nurses etc. inperforming the tasks and has a negative impact on the mindsets. Nevertheless, there are numberof failed attempts in following the guidelines mentioned by both the state and federal levels. Thisimpacts the overall health and safety of the patients and also tarnish the reputation of theprofessionals and this organization's name in the health and social care sector (Fay and et.al.,2019). Therefore, it must be followed under the ethical standards to use the media in better waysby providing safety to the well being of the patients.D2. Recommendations for improvementThe authorities and the professionals of International Hospitals Group must comply withthe guidelines and the policies structure to minimise the reputational risk. Their focus must be toimpart education for giving proper services in context to both quality and delivery of services.Along with this, they must generate awareness among the patients and their families to have acommand on the record keeping and gain knowledge in understanding the reporting and thetechnical details attached with it.LO 2P3. Description of Records storing This is significant due to gaining insights about the patient's information in relation to theauthenticity by checking the background, insurance availability and nutrition (Lam and Fresco,2015). Along with, it maintains the differences like public information, restricted details etc. thatare prevalent during the filling forms for better assistance in giving the adoption of electronicsystems. Moreover, it helps in maintenance of privacy and confidentiality when sharing theinformation through using secure systems as it helps in recording the errors while reporting.Thus, to maintain accuracy and using databases to keep the information about treatmentprocedures, scanning or x rays etc. such storage of records prove effective and generatesprofitability in context to financial gains, enhanced levels of time, energy and resources as well.P4. Reasons for sharing information within own setting ans with external bodiesThis information of patients and the information or data must be shared when requireddue to easing out the medical procedures which is mostly very long and cumbersome. Alongwith, it emphasis on identifying the challenges and help in giving better services and provideintact support to them for speedy recovery (Phillips, 2016). Furthermore, this must be sharedwith external bodies like COC, NICE etc. to have a more robust and centralized system ofkeeping the information at one location avoiding any delays or confusions. The sensitiveinformation must be kept in public records and this is useful when conducting any public healthinvestigations or addressing the complaints or queries of the affected patients. It is important to2

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