Effective Reporting and Record-keeping in Health and Social Care Services

Unit 17 Effective Reporting and Record-keeping in Health
and Social Care Services

Table of Contents
INTRODUCTION...........................................................................................................................3
MAIN BODY...................................................................................................................................3
Describing the regulatory and legal aspects associated with the record and report keeping
within the care setting.................................................................................................................3
Exploring the external and internal record requirements associated with the care setting. ......6
.........................................................................................................................................................9
REFERENCES..............................................................................................................................10

INTRODUCTION
The aim of my assignment is to review the reporting and record-keeping process related
in own workplace. In this report will be discussed about the legal and regulatory of record-
keeping and the importance for care service manager and their staff. In addition to this, they must
keep lots records in place for service user`s welfare. There are some statutory requirements put in
place by inspect bodies (CQC) from good equipment, maintenance recording staff and service
users to be exactly their aids and applications are being properly maintained. This system entails
report keeping is planned, reviewed and general improvement. Also, it includes the storage and
access of records and how to gain access to them when is requested by person. According to
confidential data protection when sharing the information must be addressed with reference to
the requirements of Data Protection. This would help in giving service user with greater choice
as well as control of treatment and support services with encouragement to live normal life.
This study will focus on describing the regulatory and legal aspects associated with the record
and report keeping within the care setting. Moreover, this study also focus on exploring the
external and internal record requirements associated with the care setting.
MAIN BODY
Describing the regulatory and legal aspects associated with the record and report keeping within
the care setting.
Every staff member within the health care setting is highly responsible for effectively
maintaining the reliable set of records and effectively reports the same to the supervisors. The
records must be effectively authorised by the patient by the lasting power of the attorney. There
are several other breach associated with the practice and protocol. The Secretary of State for
Health has effectively ordered the national regulator which helps in conducting a review related
with the data management procedures and processes across all the health and social care setting.
Statutory requirements
Report and record-keeping is very important in healthcare sector as is provided good
practice of
storing of information being kept safe, then the patient has free access to them when they
request to benefit from this in many ways. The care provider must keep all documents up to
date and following the regulation. Legal requirements set out clearly how keeping of records

should be stored and the regulation health and social care act 2008 explain why records are
needed. The care providers need to follow the guidance by:
-keep accurate records about the patient needing service
-keep corresponding records about the employed staff to provide the service
-requires any paper or electronic documents to be kept secure and put in place for easy
access
-record should be kept in appropriate period of time and after a time must be safe destroyed.
-record about treatment for every patient
-record all messages about patient like treatment care including phones calls
-keep the record up to date
-recording is carried out promptly, accurate and factual.
Statutory requirements of recording and reporting
The proper records of the patient must be made and must be kept highly confidential. The
records must be reported to the regulatory body or anyone of superior authority (Redmond and
et.al., 2020). The data recorded must be highly transparent, integrity, accessibility, compliance
and protection. The report mainly comprise of payment, claims adjudication, enrolment, etc.
Legal and inspecting bodies regulatory aspects
Parts of record keeping around regulation for conducting the information confidential and ethic.
When sharing the information is important who require that information. Own organisation
contains personal information about service user and is protected in legal manner. The keeping
reacords is important for the health of the patient and is increasing the level of trust. Also, the
regulatory obligates the care setting to share the information, also handling of information
involves protection for patient taking health and social care. The main part of health care
delivery is the practices for keeping maintained records. There are some laws and regulation to
help to keep records safe:
- Data Protection act 1998 which are helpful in this matter
-The GPDR regulates the use of information needs to be in line with confidentiality of the
information and the need of organisation (ICCO, 2018)
-The Health and Social Act 2008 has different aspects that must be carry on in care setting to
adopt good practice towards record keeping and reporting. (Griffith and Tengnah, 2010) The
registered