Effective Reporting and Record-Keeping in Health & Social Care

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
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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
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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
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