Record Keeping in Healthcare: Legislations, Regulations, and Internal/External Requirements

Health care records
Healthcare records
Name of the Student
Name of the University
Author Note

Record keeping1
Response to LO1:
P1:
Correct record keeping procedures helps in creating an efficient working process in a
care setting. There are various laws, which apply to a care setting that determines the time
length for record keeping (Gupta and Choubey 2019). Three legislation and one regulation
governing the record keeping in health and social care will be discussed in this section.
One of the legislative acts is the Data protection Act 2018 which has seven parts
contained in it. These parts are-
1. Provision about personal data processing.
2. Personal data processing subjected to GDPR.
3. Part 2 is associated to GDPR
4. Part 3 creates a provision about personal data processing by selected and competent
authorities concerned to law enforcement purposes.
5. Part 4 is responsible for the processing of the personal data by intelligent services.
6. Part 5 is responsible for the provision about the commissioner of information.
7. Part 6 creates provision of the enforcement of legislation related to data protection.
8. Part 7 creates a supplementary provision which includes the provision about the
application of Act to Crown and Parliament.
Another legislation is Health and Social care Act 2008 devised by the government of
United Kingdom. This act was imposed on March 11, 2009 and had a few activities included
in it. According to this act, healthcare to the patients will be provided by the National Health

Record keeping2
Service Foundation trust (Carey 2018). A Primary Care Trust can provide healthcare to the
patients. The foundations will manage NHS Blood and Transplant of organs. The Care
Quality Commission are responsible to ensure services providing the quality when regulated
activities are carried out (Bayliss et al., 2016).
The third legislative act is Freedom if Information Act 2000 was devised by the
parliament of the United Kingdom. This act creates a right of access for the public to all the
healthcare services. This act is implements the manifesto commitment of the Labour Party in
1997 general election.
The regulation laid down for data protection is the General Data Protection
Regulation (GDPR) devised by European Parliament and Council in the month of April, year
2016. GDPR includes several principles which are stated as follows:
1. Consent requirement from subjects required for data processing.
2. The collected data should be made anonymous to preserve the data privacy.
3. Preventing data breach and informing data breach notification data.
4. Controlling the transfer of data across borders and handling them safely.
5. Recruitment of certain companies for the appointment of a data protection officer to watch
over the GDPR compliance (Burns, Johnson and Honeyman 2016).
The primary purpose of GDPR is to implement a law of data security on every
member of Europe. Therefore, it can be stated that GDPR affects over the data protection
requirements on a global basis (Portal 2018).
Healthcare providers are expected to do in line with the requirements of the
previously stated acts. They are expected by the government to follow the guidelines stated in

Record keeping3
the act for the proper maintenance of medical records in different healthcare institutes
throughout the world. Each of the healthcare providers are provided with information related
to the guidelines given by the legislations and regulations stated above.
The healthcare setting concerned in this study will be implemented with the rules and
regulations of these legislations. The setting will be provided with information sheets
associated with the data protection act guidelines, preserved inside the setting. All the
workers of the healthcare services including medical professionals will be made aware of the
fact related to data protection and its regulations.
On a concluding note, it can be stated that there are several legislative and regulatory
aspects of record keeping in a healthcare sector. A proper functioning of healthcare institute
is guaranteed provided the legislations and regulations are followed.
P2:
CQC (Care Quality Commission) plays a significant as an independent regulator
required to register and report on health and the adult care service providers of England. All
the GP practices will be registered with the commission (Harris and White 2018). CQC
registers the care providers, monitors and inspects the rate services, takes action for people
protection using the services and publishes the views on major quality issues in social and
healthcare services. Therefore, it can be stated that, in this way CQC maintains the record
keeping and prevents data breaching in the healthcare services throughout the world (Healy
2016). CQC protects the rights of people vulnerable to the disadvantages of data protection
breaching and including people restricted under the Mental Health Act. Involving the public
and people who are associated to receiving the healthcare services. The values of CQC
includes caring, integrity, excellence and teamwork which together helps in preventing data
breach and protection of medical records.