Importance of Record Keeping in Healthcare Settings

This report discusses the importance of record keeping in healthcare settings, focusing on the impact on patient care and legal protection. It explores the methods of keeping records, such as hand-written or technology-based documentation, and the benefits of good record keeping. The report also covers the internal and external record requirements in healthcare.

Healthcare Settings
Record And Report

Table of Contents
INTRODUCTION ..........................................................................................................................3
TASK 1............................................................................................................................................3
P1.................................................................................................................................................3
P2.................................................................................................................................................4
P3.................................................................................................................................................5
P4 ................................................................................................................................................6
P5 ................................................................................................................................................7
TASK 2............................................................................................................................................7
Covered in Poster........................................................................................................................7
CONCLUSION................................................................................................................................7
REFERENCES................................................................................................................................9

INTRODUCTION
In healthcare organisations, there are number of reasons to keep records of individuals in
order to bring accuracy in their treatments. It is very essential in any health maintenance and
social organisation for compiling an overall documentation of individual's journey throughout
the services. It assist in enabling the consistency of care in the treatment during delivery of
clinical services. Records and reports keeping in healthcare must be accurate, clear and concise
(Maragh-Bass and et. al., 2017). However, number of methods are there for maintaining records
in healthcare such as hand written records or technology based documentation or sometimes a
collaboration of both. In this report, Chetwynd House Care Home has been chosen which is a
family run based care home and provide luxury quality care to the individuals. Furthermore, the
report is going to cover lawful and regulative prospects of coverage and keeping records in
health and social care centres. In addition to this, external as well as internal recording
necessities in home care services has been discussed. At last, keeping an maintaining records in
own care settings has been covered.
TASK 1
P1
Documentation and keeping records is important for service users as well as healthcare
professionals. Accurate reporting and record keeping by noting of all prospects of service users
analysis is necessary as it builds an integral part of care and health care management of patient
(Bastian, Munoz and Ventura, 2016). It is require to keep records in Chetwynd House Care
Home as it helps in to circulate the information within teams involved in patient treatment. From
legal perspective, record keeping or documentation is necessary for the protection of health
practitioners. A well documented record of a patient will help health practitioners in instances
where a legal defence of action is require.
Reporting is also a necessary requirement in healthcare as it has an ability of analysing
current as well as historical data of patient and to spot the medical issues in them even before
they occur. Respective organisation should develop reports of their service users for enhancing
their care quality and to deliver high service quality (Brown and et. al., 2016). Record and report
keeping ensure a scope of professionalism and it is a prof of improvement. Such kind of
documentation will help in to monitor diseases through using the present and past data of an

individual. Preventive measures could be develop if such type of predictive identification is done
through using records.
Healthcare documentation will make operations of the organisations cost effective.
Analysing daily expenditure of organisation by the means of keeping records will help them to
maintain budgets procedures and to make necessary changes based on ethics, safety and trusts.
Documentation and reporting could help respective organisation for determining efficient
of their operational processes and current status of their patients. It will help the organisation to
improve the reproducibility and productivity by making certain required changes (Hemsley and
et. al., 2016). A proper healthcare report and record could provide assistance to care homes and
healthcare organisations for providing relevant information to their patients regarding their
treatments and services. Thus, record keeping and reporting in care homes are require to
maintain treatment and services of the patients.
P2
Record keeping consider as all the paperwork and digital record conformity data which
necessarily for keeping by care workers to accomplish their compel in region like safety and
healthy, finance, book keeping as well as employment law legal protection, most importantly,
registration, medical and care records (Wood and et. al., 2017). Care practitioners record and
keeping records should abide by with both the related to care modular and regularise and broad
data activity legislatures, which have been thoroughly altered with tenderness.
The CQC Standards Compliance, the health and social care Act keeping necessitate under spiel
like good administration, paragraph, the certified person.
Maintain firmly an faithful, absolute and contemporary evidence in regard of each service
consider a attainment of care and attention supply to the divine service user and of conclusion
interpreted in relation to the care and attention furnished, hold up layperson such as other records
as are essential to be kept in abstraction to-
 Persons employed in carry out the controlling activity.
 Managing the controlling activity.
 Comprehensive, legible, accurate and up to date or comprehensive
 kept private and securely and only accession, unamended or annihilated by persons
authorized .

Wales standards compliance with the execution of the standard of healthcare centres.
Act the evidence conformity for all care employment is ordered in line with standard .
 Keep and maintain all required records accurately and up to date.
 Meet the postulate of data protective cover Act .
 Guaranteed electronic records are password protected.
 Have a policy and activity for the management of records.
 For patients to have access for their own details and any other data held just about them
by the home (Cochrane and et. al., 2017).
P3
During care of an individual it significant to assure better keeping records to encourage
care for patient and good human activity. A better record keeping in health and care is a creation
of a better team or an essential agency in development of high quality health care in Chetwynd
house care home or strengthen expertness with nursing. There are many reasons to keep record in
healthcare which is winding up the overall documentation of patient journey by means with
services (Han and et. al., 2016). To modify cohesiveness care for patient both within and
between employment.
Methods of keeping records in healthcare.
 computer based, Hand written, some organisations or staff members will use a
combination of both.
 It is assure the information should be up to date and tools and techniques in organisation
and in workplace including their security.
 Make sure, don't left written records publicly where there might be chances of public
access, including displays and electric systems (Kakyo and Xiao, 2017).
 Patient medical record which guarantee that an entry is made for the clients when a care
practitioners look after their service users.
 Protect details and passwords given them to enable access any systems.
 Make sure that current and latest tecchnology information tools and systems in hospitals
and office which include confidentiality, security and appropriate usage.
Components of patients records include:

Medical records, medications handover sheets, charts and admissions, venting as well as
conveyance list as well as letters, patients assessment forms like nutrition or pressure level care
assessment (Minogue and Wells, 2016).
Benefits of good record keeping
A record must be made as soon as affirm-able after the patient is seen or the process is
complete. It is important that straight record is made by patients notes and should consider
participation and response to the group action.
There are some legal issues to keeping good records, The duty of care to the patient has
been interpreted including care that has been conceived and provided, set up have been made for
the current care of patients.
P4
healthcare settings record and report
The report concise the employment of the social worker or the authority. Reports may be
in the from of examine some prospect of work. These are supported on records and registers and
so it is applicable for the care practitioners to hold up records with respect to their service case
load, daily case load as well as activeness (Redmond and et. al., 2019). The main reason to keep
records in healthcare and hospitals to assure coherence of care for patients and client also for
judicial function.
The effectual communion information sustain incorporate working and is a critical
section of of both primary intervention and setting of register and record the data in healthcare.
Service users development and health and any influence to possible harm, parent who
may need help, and not unable to care for a child adequately and safety as well as those who may
pose a risk of harm to a child (Hodgson and et. al., 2016).
Care worker must be retroactive in intercourse content as soon as possible to recognise
and help, evaluate and react to risk or considerations regarding welfare and safety of service
users. Practician should also be wakeful to joint necessary knowledge regarding any adults for
whom that patient has link, Which may effect on safety of workers as well as patients.
The participation in health care delivery of different kinds of persons and groups or units
of supply utilize strong pressure to papers in every greater detail. The enlarger numbers of
accessible application for diagnosis and medical care mean that inside information that a supplier
could at one time request to must now be canned and thus become acquirable for examination by

others (Almirol and et. al., 2018). Rather than some other content of lifestyle such as family
history, health status have turn or larger involvement and relevancy as they acquire and know
about the these component to general health and well being. As well as they written record their
genetic data that are more promptly acquirable which is not for antenatal testing but also for
evaluate person state of risk for an heritable condition.
P5
It is very necessary to record data of patients for their foster treatment reported to their
necessitate, so there to type of data that expatiate in term of internal and external postulate. In
this internal record is that can consider information systems for example such a radiology
information system, or the patient financial system, a cancer registry (Dean, Victor and Guidry-
Grimes, 2018). The sources of internal data are associated data explanation and the structure of
data in database, how time and quality relate or it surface or incorporate with other internal
systems, classification or nomenclature is needful.
In the case of internal record it is more faster and prompt care which get rid of and need
to duplicator or transfer whole files between networks. This allows them to go home earliest and
work from institution. And other is better visual communication and greater direction accuracy,
built act etc.
On the other hand the external record are also necessary for individual and care-workers
also, the main reason for hold up external records is to assure coherence of care for patient, they
also involve for judicial intention for example the patient prosecute a assertion following to read
traffic misadventure or an injury at work (Stewart, Vigod and Riazantseva, 2016). And it is the
digital interpretation of patient paper chart, they comprise a patient medications, medical history,
and treatment plans allergies, diagnosis. radiology images, laboratory and desired outcomes of
tests. As well as they automatize and contour render progress.
TASK 2
Covered in Poster
CONCLUSION
It has been concluded that the record keeping in healthcare should be manage
appropriately. This includes the service users and this is the most effective way to build a
relationship between the service providers and users. This also improves the quality of

organisation among to the authorised organisation by maintaining the record and submitting the
report to the organisation. It also helpful in building the self-esteem of users among all the health
and social care. By conducting training sessions in an organisation help care centres to keep
record and report the records to the authorised organisation on a better level.

REFERENCES
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