Effective Reporting and Record-Keeping in Health & Social Care

This document provides an overview of the statutory requirements, regulatory bodies, and process of storing records in health and social care settings. It also explains the reasons for sharing information within the setting and with external bodies, as well as the benefits of involving service users in record keeping.

Unit 17 - Effective
Reporting and
Record-Keeping In
Health & Social Care

Table of Contents
INTRODUCTION...........................................................................................................................2
TASK 1............................................................................................................................................2
P1 Describe the statutory requirements for reporting and record keeping in own care setting2
P2 Describe the regulatory and inspecting bodies’ requirements for reporting and record
keeping in a care setting.........................................................................................................4
TASK 2............................................................................................................................................5
P3 Describe the process of storing of records in own care setting.........................................5
P4 Explain the reasons for sharing information within own setting and with external bodies7
P5 Accurately illustrate the internal and external requirements for recording information in
own care setting......................................................................................................................8
P6 Describe how technology is used in recording and reporting in own care setting............9
P7 Explain the benefits of involving service users in record keeping processes.................10
P8 Produce accurate, legible, concise and coherent records regarding service user care for
different service users following own setting’s guidelines..................................................11
P9 Explain different aspects of own management of service user records with reference to
compliance with national and local policies and guidelines................................................14
CONCLUSION..............................................................................................................................15
REFERENCES..............................................................................................................................16
1

INTRODUCTION
The record keeping is an effective approach that is used within the health and social Care
organization. It must be occur properly so that entire quality of record can be maintained. This
also provides effective interactions between patients with their healthcare professionals. This
provides help in maintaining confidential and accurate records of patients. The reporting must be
effective so that it can help in analyzing various aspects of services that are providing to patients.
The Reporting and record refers to the exchanging of information between service providers and
users. With this the service users can take appropriate decisions about their health services. In
this assignment, the various situated requirements are described that are necessary for record and
report keeping in NHS healthcare setting. Along with this there inspecting and regulatory bodies
are also included in this that has requirements for record and report keeping. As there are various
process of storing records within a healthcare organization. Moreover there are various reasons
for sharing information between on setting of organization with external bodies. The internal and
external requirements are necessary for recording and maintaining information in setting of
organization (Qiu and et. al., 2019). There are various technologies are also used within reporting
and recording of information along with there are also various benefits of involving service users
within process of record keeping. The production of accurate and current records according to
service users from service providers occur within their guidelines of NHS care setting of
organization. In addition to this, there are also different aspect occur regarding service
Management of record of service users under the guidelines of various different National and
local policies. There are processes of record and reports keeping are covered in this report.
TASK 1
P1 Describe the statutory requirements for reporting and record keeping in own care setting
There are various requirements are needed for record and report keeping within NHS care
setting of organization. As report and report keeping is an important aspect while delivering
services to service users. With the help of this service users can attain various benefits in
different ways. From good record and report giving, the staff and service providers can provide
appropriate information about their services. It also helps in minimizing the safety risk that may
occur within the services of patient. There are also various legal requirements in record and
report keeping are also occur which are need to be followed by organization. It also involves to
2

keeping record and reports in an accurate form with appropriate information of service users.
Including this, the maintaining of recording and reporting must be confidential and it does not
disclosed to other service users (Hastings, 2018). In addition to this there are basic requirements
for record and report giving within on care setting of organization. The record and report giving
must include the information about services that are providing to service users. This could be
occur in an appropriate manner so that information does not mismatch.
The formation of record and report keeping must be occur in a systematic manner so that it
can be used to plan and describe the treatment for services according to their needs. The record
must be up to date according to the treatments that are provided to individuals. Including this, it
must be reported to other quality commissions so that there further treatment care plan can be
plan. The record must be factual and accurate so that it can carry out properly within the NHS
setting of organization. The formation of record-keeping must be confidently so that it can help
in maintaining the dignity and respect according to the needs of person. It should not be
judgmental and abusive including it does not harm the integrity of an individual.
The formation of record-keeping must be occur in a proper manner so that it can state
about the person properly. The manner of record must be proper and under the guidance of
professional and agencies so that their future treatment and care can be planned. The record
keeping information must include various strategies that need to be made within keeping them.
The formation of record must be formulated according to the preference of patients by
communicating them whether the patient describe about his needs in a way. It must all write up
in the record so that future steps can be taken with their services. The record must be cap security
with proper legal formation. The report giving must be occur on a regular basis to all people who
are associated with the services of a service user. This also involves occurrence of report and
record for a longer period so that it can properly summarize to nurses and various other agencies.
The report giving also includes the activities and observation of service users from which their
behavior and other impact can be properly analyzed.
There are various different type of reports occur which have different criteria. This
criterion believes that a report must be clear and complete so that it can understand to all
professional and nurses properly. There are various important points that are needed to be
considered while delivering services to patients and need to be emphasized within report
keeping. The maintenance of record and report keeping provides continuity of services to service
3

users along with including their families with in it. They must implement according to the
policies and processor so that their quality of keeping can be properly occurs (Cree, Jain and
Hillen, 2019). They also have a proper assurance of quality from which quality of services can be
managed properly. They also must have proper records so that it can facility various
requirements and services that are developed for the promoting and influencing services for
services users. This is necessary to be applied within organization as the other organization is
filled in maintaining creating report in record keeping organization. They don't have proper
medical records and safety programs with their services. This security requirements are need to
be followed by the manager of organization so that record and report keeping must be occur in a
proper manner.
P2 Describe the regulatory and inspecting bodies’ requirements for reporting and record keeping
in a care setting
There are various requirements of inspecting and regulatory bodies occur in order to
maintaining report and record keeping within a care setting of organization. Within this needed
legislation, judicial function and executive so that they can empower facilities that are present in
organization. The implementation of different types of laws and legislation of record and report
keeping is beneficial for organization so that they can regulate their forces of maintaining report
and record (Cairns, Jonas and Wallis, 2018). There are all the various standards of record and
report keeping which is occurs in in regulatory bodies from which they are referred as entities of
government. These are made up of on the basis of legislation that is mandatory to follow by
organization. In this they also include various number of programs for which they can provide
various subsidies to organization. The requirement of this regulatory and inspecting body is to
enforce regulation and standards within the setting of organization. Their main objective is to
provide efficiently so that organization can maintain record and report keeping properly.
There are various implication develop due to non-compliance with regulatory legislation
inspection bodies. As with this the organization is not able to provide on quality of services
among patients. They found various difficulties within record and report keeping about
information of services that are providing to patients. Due to this the various complications can
occur within the services of services. Including this, dissatisfaction of services among patient
develops. If the organization does not follow appropriate rules and law which are implemented
by regulatory bodies then they has to suffer various consequences with their services on the
4

setting of care. The mismatch of various information of a particular patient develops from which
application can be arise within the services of patients. In addition to this, the confidentiality of
information of any patient is disclosed among other patients and people who may develop
satisfaction among patients with their services and disrespecting their dignity.
There are also various consequences occur from non-compliance with regulatory bodies
with reference to safety of service users media and the credibility of organization. These
consequences include reputational woes, impact on safety of service users and effect on the
credibility of the organization. Due to the non-compliance with regulatory bodies the reputation
of organization affected and it was popularized by media which develops various effect on the
image of organization. From this the safety of service users bad effects. As the organization does
not maintain appropriate information of their patients.
In this various that impacts on their services as the service users may leave and neglect to
attend services from organization (Saeed, 2018). The patients does not feel confidential
environment according to their needs for their services as they have threat of disclosing about
their information to other people. This causes other impact on their services as a credibility of the
organization decreases. The services of organization do not trust by customers and various other
partners who are associated with it.
TASK 2
P3 Describe the process of storing of records in own care setting
There are various ways from which record can be store within NHS care setting. The
process of storing records need various requirements including legal and identification of
requirements of service users from which organization can access to manage in record keeping.
This process of keeping records is described below.
 It is necessary to determine the resources that will need it for storing of records. As while
maintaining records there are various things that need to be included and responsible for
maintaining it. This also includes implementation of various legislation and regulatory
bodies which help in developing and maintaining of records within the system of
organization.
 After this with in the process of record storing, it is necessary to identify them from activity
and function of professionals with in NHS care setting. The each individual has their NHS
5

information which are need to be confidential (Kimei and Kalegele, 2017). So the
professionals and manager of organization must capture information from service users.
Then they need to meet record with appropriate method of communication with service
users. Including this, the environment of various types of area within storing record. Then it
is necessary to match the records according to the schedule so that complication does not
occur while delivering services to service users.
 The information that has gathered from service user, it is necessary to recheck them whether
it appropriately recorded or not. That should be a girl on a daily basis for the error would not
arises (Tough and Lihoma, 2018).
 The information can be stored by using different technologies within the system. This
provide more confidentiality and prevention of any harm of can be achieved. The use of
digital forum helps in recording and storing record within a given time which helps in in
influencing the services of organization among patients. With the help of these technologies
the records can be stored in safe manners so that other individuals cannot get in touch of
records. In addition to this, the records must be store under the governance of legal
requirements so that it can properly Store.
 After this it is necessary to review the record that is there are properly stored or not. This
provides the assurance of storage of records. Moreover, it is necessary to identify the ways
from which record can be stored properly. Including this, each type of record has their NHS
way of storing so it is necessary to identify that manner (Coneo and et. al., 2020).
 The creation for a location in which record can be stored. While maintaining record it is
necessary to develop proper security so that it cannot be damage. Show the development of
security procedure in within records also provides prevention from unauthorized access
which develops loss of record.
 Then the development of different procedure from which in active records can be prevented.
This should be a part of organization operation from which shift they can transfer records on
a long-term storage. It also involves the tracking system from which location of records can
be track.
After this there are various policies and procedures are needed to develop from which
various expired records can be destroyed. The current process within NHS care setting is used
within the form of latest technology of storing and sharing records. The implementation of new
6

technology helps operation manager in keeping records from up to date with new trends. The use
of new technologies provides various benefits to service users from which the image and services
of organization can be influenced among other service users. The involvement of various policies
including local and national guidelines that provides manner from which organization can store
record.
P4 Explain the reasons for sharing information within own setting and with external bodies
The sharing of information is an important aspect within the organization while leaving
services to patient. As it provides safeguarding and trust to service users from which health of
patients can be promoted. The sharing of information also provides and assists in various
problems that can be emerged. When the information is shared with service users them the
proper quality of services emerged. The other professionals and workers have the opportunity to
develop more confidence of services by developing communication with their patients. This is
necessary to provide appropriate information about their services within NHS care setting. It
provides a framework among individuals from which the personal information about dam is
appropriately shared with them. This does not allow any break off any law which is developed
for the welfare of service user (Liu and et. al., 2017).
With this proper sharing of information provide trust between service user and organization.
With the help of sharing information it is easier to understand the needs and requirements of
services from which services can be provided appropriately to them. By proper communicating
with patients, it has been identified that what information is necessary to be shared with further
bodies. While at the time of sharing information with other members develops various impacts
among patients which develop insecurity and distrust for professionals and organizations. What
are the help of sharing information the welding and safety of individual can be considered. As
there are various external bodies are present, then sometimes sharing of information is an
important process of delivering services to patients.
Thus, sharing of information without permission from service user is reason sharing
information with other external bodies. This is only occur when the information are directed by
law or court. With the help of sharing information with service was the more effective and
efficient services can be provided to individuals. With the help of sharing information by
communicating with individuals, more needs and requirements of services can be analyzed
which can be used in further intervention and services. From this it provides protection and help
7

in promoting welfare to patients by safeguarding them from any type of risk. There is no
involvement of other external body is also provides legal protection and standards to
organization from which they can determined for the prevention method for individuals from
which there health can be enhance (Tingle, 2017).
The purpose of sharing information weather in NHS care setting and external bodies
provides potential impact on the health services of individuals. There are various professionals
occur which have their own role. So, by sharing information about patients can help in providing
appropriate services according to the needs of individual that is necessary to be occur with their
services. The involvement of external bodies and on gear setting professionals within the
services by coordination of information of services provides more efficient services to individual
from which their health can be promoted. With proper sharing of information does workers and
staff members can use up to date services with the use of guidelines from which they can provide
appropriated services to service users.
P5 Accurately illustrate the internal and external requirements for recording information in own
care setting
They are some internal and external requirements are necessary for recording information
within NHS care setting. There are different types of internal requirements are occur which
includes procedure of record keeping and instructions on which organization follow the process
of record keeping. Within the requirement of internal with in organization required format of
keeping record information (Jafar, 2020). This also involves use of various technologies and
electronic technologies that help in recording information within setting of organization. From
this organization can appropriate record information that can be under stable to all people who
are associated with the services. This also involves the use of digital electronic method from
which the record of information becomes easier for organization.
They are other internally requirements that is involvement of services within recording
information. As with this, the proper information can be recorded with determining the needs and
requirements of service users and their families. The given organization uses these requirements
internally so that they can record information properly. Along with this, the different types of
processes are followed by an organization which is a part of internal requirements. This provides
various beneficial to organization within their recordkeeping from which they can successfully
implement of storing record. There are some regulations and rules are occur within an
8

organization that has them developing and storing their record properly. The involvement of
services also helps in shaping of information in record which cannot be disclosed to others.
The external requirements of recording information provide involvement of other
organization and guidelines which have different infrastructure of recording information (Hann,
2016). The External bodies have different guidelines and standards for recording information.
There are various validation are provided from external which provide other security standards
of data. The NHS has their arrangement and process of storing and retrieving information occur
as internally. As they prefer to develop their own regulations from which they can store and
share information properly. There are various standards are provided by external agencies from
which sharing and recording information can be done properly. The organization independent for
their data security with their effective communicating and leadership power from which they can
manage security of information properly.
P6 Describe how technology is used in recording and reporting in own care setting
The technology is an appropriate method of recording and reporting within NHS care
setting of organization. With the help of this the records can be maintained properly by
maintaining confidentiality of service users. This is also help in in developing various impact on
service user form which their data and information can be stored in a proper manner. With the
help of different technologies data can be stored properly (Sanderson, 2017). This also provides
medical management and care plan with the use of digital technology in maintaining records.
The technology can be used by different method as there are various new technologies occur
which helps in providing and maintaining records and report on a large area. These new
technologies are occur as digital from which provide easier to maintain the record and report. As
the use of digital technology, it provides appropriate care plan among service users by managing
their medical procedures properly. From this appropriate confidential information can be transfer
from one person to another by maintaining their confidentiality.
As they have issues of paper in record and report from which the loss of confidentiality of
information is highly occurred. The use of new technologies it is easier to convey with patients
from which their needs can be determined. The involvement of these technologies provides
organization to develop record and report with paperless. From this, the organization can
implement various solutions without developing a border on the structure of organization. With
the help of such technologies disease, injuries can be a perfectly transfer to all people who are
9

associated with and services. With the use of new technologies within the system of organization
the procedure of medical management for care plan can be occur efficiently and accurately
(Taylor and et. al., 2018). After the development or implementation of new technologies security
and monitoring does not provided on the regular basis as with the help new technologies the
records can be maintained properly under the guidance of legislation. The effectiveness of using
technology provides appropriate meet of service users.
This also helps in ensuring about care plan that is provided to patients by determining their
needs. The use of digital technology helps in maintaining confidentiality of service users from
which trust and confidence among patients can be developed. The effectiveness of using
technologies also help in analyzing the needs by digital technology from which there need can be
remain confidential. This provides benefits and services of patients from their health can be
promoted. This also provides proper medical management from which they can enhance their
sources and their pen among patients with their own setting of organization.
P7 Explain the benefits of involving service users in record keeping processes
There are various type of benefits occur in involving service users within record keeping
process. From this, the positive medical outcomes can be developed which is the base of improve
health and welfare of service users. When the service users are involved in their record keeping
process than their self-esteem and confidence level improved which deliver various benefits in
their health and well-being (Gillies, 2018). This is also coordination and communication between
healthcare professionals, workers and service users from which their needs and requirements can
be analyzed more. The involving of services users within process of record keeping it provide
potentially lead of more healthcare services to patients. There are various acts and legislations
are occur which provides the dignity and respect station of their services. So involving the within
record keeping also help in maintaining their dignity and respect from which their health can be
promoted.
The involving patients within the decision of record giving process provide positive
outcomes from service users as they feel confidence and respect from organization. They can
provide the flexible for their services more within services of organization. There are some other
benefits of involving service user is that they can ensure about their choices that are early
describe to health professionals and workers. The involvement of patient with and record
keeping services provide and help in enhancing the quality of record keeping properly from
10

which effective services can be delivered to patients. This also develops involvement of their
appropriately within their services from which we can improve their health by themselves
(Coates and et. al., 2017). With involvement of patient the record keeping can be shaped in a
proper and actively manner from which the services can be improved with the help of national
and local guidelines. From this the person centered care can be provided to individual which
supports them to enhance their skills knowledge and confidence from which they can effectively
manage their care plan. In addition to this, the individual can make their decisions regarding their
own healthcare.
The involvement of users also provides positive effect on the system of organization from
which they can develop satisfaction of their services. the various beneficial resources can be
develop and provided to service users who are involved in record keeping process. The help of
environment the unnecessary features and expensive can be removed within record keeping
process. From this, the system can be improved by implementing various requirements that help
in developing quality of services among patients. The involvement of service users helps in
developing more reputation of NHS organization among service users. It also assists in
developing activity and respect among service users among staff members and professionals
(Holden, 2020). The Preferences of family members and patients can be considered by the
involvement of them within record keeping process. By the environment of services they can be
encouraged and facilitate for their services.
The involvement of service user in record keeping process is an effective way of delivering
services to patient from which there have can be promoted. The various other risks can be
reduced made by involvement of service users within the process of record keeping. The
communication and coordination can be developing from which healthcare professionals can
also communicate about other services to patients.
P8 Produce accurate, legible, concise and coherent records regarding service user care for
different service users following own setting’s guidelines
It is necessary for the organization to develop accurate, legible, concise and coherent
records in relation to service user care for different service users. Hence, the organization that is
being taken into consideration is National Health Service and there are several guidelines of the
organization related to development and maintaining of records. Some of these guidelines are
explored below:
11

 The incident must be fully reported as per the information from the witnesses for further
risk assessment
 Patient must be identified and all the personal and medical details must be presented
within these reports
 There must be accurate description of time of arrival, individuals handling them, as well
as time of departure (Proctor and et. al., 2019).
 All the necessary details related to the incident, which could be used to assess the severity
of the overall case and health of the patient must be provided within the report to ensure
its accuracy and relevancy towards the service users.
Thus, as per these guidelines, there are two reports which are produced for two different
service users within the care facility.
Service User 1:
Incident Date 27th March, 2020
Incident Time 5:18 P.M.
Incident Details The patient suffered severe chest congestion and possible
paralysis
Location London, United Kingdom
Patient Details
Name: Mark Hunt
Age: 78 Years
Gender: Male
Communication preferences Patient understands English and hand gestures effectively.
GP Details
The service user has been referred to a general practitioner in
his locality, who provides medical assistance and medicinal
requirements of the patient.
Medical history
Patient has been suffering from heart-related issues from last
20 years, for which he has gone through two heart surgeries in
the past. However, this is the first scenario of the patient being
this ill physically
Treatment Provided Emergency services have been provided to the patient, along
with necessary CRP process to get his heart responding back.
12

Responsible Health
Professional
Two cardiologists and five head staff members are responsible
towards taking care of the patient and his health condition.
Service User 2:
Incident Date 28th March, 2020
Incident Time 2:00 P.M.
Incident Details Patient met with an accident which caused multiple fractures
in arms and legs
Location Heathrow Airport, London, United Kingdom
Patient Details
Name: Tanya Malik
Age: 22 Years
Gender: Female
Communication preferences
English is not the first language of the patient, however, the
individual is responsive while communicating in sign
language.
GP Details There has been a physician near her locality which tends to
her medical requirements
Medical history Patient suffers from asthma and has anxiety issues
Treatment Provided
The individual has undergone a minor operation in relation to
tending her bones. In this case, she has been treated with
plasters and stitches to attach the torn skin of her arms, legs
and forehead.
Responsible Health
Professional
Senior Orthopaedist, physician, a team of nurses and around 5
medical assistants have been subjected towards tending the
patient and oversee her medical condition.
13

P9 Explain different aspects of own management of service user records with reference to
compliance with national and local policies and guidelines
The organization have their NHS aspects from which they manage records of service users
with the compliance with local and national policies. The NHS organization manages record of
service user by compliance with legal responsibility under the legislation of data protection act.
With the help of implementation of this at bus service users can receive various benefits of their
records by attaining copy of their records (Launer, 2018). The various other acts are also
implemented within the system of organization from which they can successfully manage
records of services users. as the organization have different aspects with their managing service
user records which includes alphabetically management of records. This is occur in the function
and operation of organization in which day marched business and corporate records according to
schedule.
The organization has different organized and management of record from which they
distinguish according to the services and their period of time. The organization have also
different process of maintaining records within their setting which includes scanning the process
and procedures according to the care and services that are provided to patients. There are some
other methods of record keeping also occur which sometimes develop unusual conditions in the
process of record keeping. It has difficulties which occur among organization within their
managing and record keeping process. This also causes impact on reporting about information of
services (Rogers, 2018).
This provides the effectiveness of documentation from which they can provide appropriate
services to users according to their needs. With their proper scanning program and maintaining
of records we can and sure about their services and care to service users. As the organization has
effective and proper record keeping from which they can appropriately report about the
information. This is developed due to the involvement of service users with their services with
complaints of guidelines and policies.
14

CONCLUSION
From the above assignment it has been concluded that, there are some requirements of
reporting and record keeping it is necessary to be occur within organization. They can implement
proper information in store. Including this there are various inspecting and regulatory bodies
occur which are the requirement of record and report keeping. There are some process are occur
in storing of records within organization which help them in in preventing and storing of record
properly. There are also some reasons occur within organization from which they sure
information to their internal body including external bodies. As there are both internal and
external body which are necessary for recording information within care setting of organization.
There are various different type of technology can be used within maintaining and keeping
record. This provides appropriate way from which services can be provided to patients. While
record keeping processes the involving service users is a benefit approach that helps in
maintaining records appropriately. The current and accurate records can be developed regarding
services according to different service users by following guidelines of organization. There are
some other aspects occur within the services of organization from which they can manage the
record and report keeping efficiently.
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