Record Keeping in Health and Social Care Services

Effective Reporting
and Record keeping
in Health and Social
Care Services

Table of Contents
INTRODUCTION...........................................................................................................................1
TASK 1............................................................................................................................................1
P1. Statutory requirements for reporting and record keeping in own care setting......................1
P2. Regulatory and inspecting bodies’ requirements for reporting and record keeping in a care
setting..........................................................................................................................................2
M1. Analyse the implications of non-compliance with legislation, regulating and inspecting
bodies’ requirements...................................................................................................................3
D1. Evaluate the consequences of non-compliance with reference to the media, service user
safety and the credibility of the care setting................................................................................3
TASK 2............................................................................................................................................4
P3. Process of storing of records in own care setting.................................................................4
P4 Reasons for sharing information within own setting and with external bodies.....................4
P5 Illustrate the internal and external requirements for recording information..........................5
M2. Examine the current processes in own care setting related to storing and sharing records.6
D2. Evaluate own work settings arrangements and processes for storing and sharing
information, making recommendations for improvement..........................................................6
Part 2................................................................................................................................................7
Lo 3..................................................................................................................................................7
P6 How technology is used in recording and reporting in own care setting...............................7
P7 Benefits of involving service users in record keeping processes...........................................8
P8 Accurate, legible, concise and coherent records regarding service user care for different
service users following own settings guidelines.......................................................................10
P9 Different aspects of own management of service user records with reference to compliance
with national and local policies and guidelines.........................................................................11
Conclusion.....................................................................................................................................12
REFERENCES..............................................................................................................................13

INTRODUCTION
In every organisation reporting and record keeping is essential. It is considered as the
process of recording events as well as transactions. It is an crucial aspects of health and social
care services. Effectual record keeping is helpful to promote patient care as well as better
communication (Fleissig and et.al., 2017). It is a product of effectual teamwork and techniques
for creating standard quality heath and social care services. For this report, the chosen company
is Core Havencare Ltd. Which is a healthcare organisation in UK. The purpose of this report is
to explain the statutory requirements for reporting and record keeping. Regulatory and inspecting
bodies requirements and process of storing records. Reasons for sharing information with
external bodies and internal as well as external requirements for recording information.
Technology is utilise in recording and reporting in firm. Benefits of involving service user in
recording keeping methods and records are produce in respect of service user care. Apart from
this different aspects of own service management users records with references to compliance
with national and local policies as well as guidelines are also mentioned in this report.
TASK 1
P1. Statutory requirements for reporting and record keeping in own care setting
Reporting and record keeping is essential for both patients as well as for healthcare firm.
While maintaining relevant and accurate records company can facilitate better quality of services
to their employees and patients. In health and social care, reports and records are kept with the
use medical record numbering, dividers, folders and so on. For this there are requirements of
statutory. It imply treating record keeping as a total system which is planned, organised,
reviewed and developed as whole.
The statutory requirements for keeping records are set in regulations 20 of Health and
social care Act. So, its requirements in Core Havencare Ltd. are as follows:
Care records:
Care services must be capable to show that keep records of care and treatment are
facilitated to all services user. In Core Havencare Ltd. All records regarding service users, care
and treatment through their mouth words , telephone calls etc. Recording are link in confidential
way, data about individuals which relates to their care from another professionals. For all this
freedom of information act 2000, general data protection regulations 2018 and human rigths

1998 are required by respective firm. All this help Core Havencare Ltd. to access the recorded
data that is held through public sector company, to safe most vulnerable in societies considering
individuals receiving care as well as support etc.
Access to records:
Records are available to service user or legal representative concerned care and
treatment. For example: someone lacks mental capability to make decision on Core Havencare
Ltd. And employees. Thus, all should have knowledge about where records and reports are kept
and to access them (Dziegielewski, 2018). Therefore, any request to view a individual records
are addressed with reference to needs of general data protection act 1998. through this Core
Havencare Ltd. Can secure their records of patients and employees. Also, identify the data that
are stored by government and another firm about them.
P2. Regulatory and inspecting bodies’ requirements for reporting and record keeping in a care
setting
Regulatory and inspecting bodies are considered as government agency which is
established to perform a regulatory functions. Many regulatory bodies protect public from
various health risk and facilitate numerous events for people health and welfare. Some
regulatory body in health and social services are heath and safety authority, mental health
commission, medical council and so on. Some are mentioned below:
Health and safety Authority
Health and safety Authority is refer as a statutory body that is accountable for regulating
health and social care in workplace like health care premises. In Core Havencare Ltd. This
regulatory bodies is required to plan the process for accident and health protection, to line up the
duties of management, to develop, execute, review and maintain policies for health and safety.
Mental health commission:
This regulatory bodies facilitates a safeguard for individuals stay in hospital under
mental health act powers. In Core Havencare Ltd. It is required to promote, motivate and foster
the set up as well as maintenance of better and standard practices for the delivering services to
mental health care and also take whole sensible steps for securing individual interest detained.
Failure to comply enforcement notice:
Enforcement notice is considered as a formal document which creditor issue to debtors,
providing warning about taking action to cover owed money. If Core Havencare Ltd. Failure to