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

Effective Reporting and
Record-keeping in Health and
Social Care Services
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INTRODUCTION...........................................................................................................................4
TASK 1............................................................................................................................................4
Describe the statutory requirements for reporting and record keeping in own care setting...4
Describe the regulatory and inspecting bodies’ requirements for reporting and record keeping
in a care setting.......................................................................................................................5
Describe Analyse the implications of non- compliance with legislation, regulating and
inspecting bodies’ requirements.............................................................................................5
Evaluate the consequences of non-compliance with reference to the media, service user safety
and the credibility of the care setting.....................................................................................6
Describe the process of storing of records in own care setting..............................................6
Explain the reasons for sharing information within own setting and with external bodies P5
Accurately illustrate the internal and external requirements for recording information in own
care setting..............................................................................................................................7
Examine the current processes in own care setting related to storing and sharing records....8
Evaluate own work setting's arrangements and processes for storing and sharing information,
making recommendations for improvement...........................................................................8
Why do you think the public is concerned about reporting, recordkeeping and do you think their
concerns are ‘real’?..........................................................................................................................9
Recommendations................................................................................................................14
Conclusion............................................................................................................................14
TASK 2..........................................................................................................................................14
Describe how technology is used in recording and reporting in own care setting...............14
Explain the benefits of involving service users in record keeping processes.......................15
Review the use of digital technology in relation to own medical management procedures or
care plan................................................................................................................................16
Evaluate the effectiveness of the use of technology in terms of meeting service user needs,
ensuring appropriate care is given and maintaining confidentiality.....................................16
Produce accurate, legible, concise and coherent records regarding service user care for
different service users following own setting’s guidelines..................................................17
Explain different aspects of own management of service user records with reference to
compliance with national and local policies and guidelines................................................18
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Analyse the process of maintaining records in own setting, identifying any potential or actual
difficulties.............................................................................................................................19
Evaluate the effectiveness of own completion of documentation in term of meeting service
user needs, ensuring appropriate care is given and effective reporting is carried out..........19
CONCLUSION..............................................................................................................................19
REFERENCES..............................................................................................................................21
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INTRODUCTION
Legislation is defined as law and processes which is mainly created to provide save and
transparent services. In context with health and service care statutory requirements play most
important role which is essential to maintain confidentiality and transparency (Cunningham,
Taylor and Murphy, 2020). There are number of legislation such as data protection policy,
confidential policy health and safety policy and procedure, enforced by government and are
required to be effectively adhered by organisations. Present report includes discussions related to
statutory requirement for reporting and record keeping. Along with this report include the use of
technology for recording and reporting and the process of maintaining records.
TASK 1
Describe the statutory requirements for reporting and record keeping in own care setting
Healthcare organisation is one of the most important sectors which are associated with
providing Healthcare services and facilities in order to protect and safeguard individual health.
However it is essential health care organisations to abide some statutory requirements. In terms
with organisations like NHS it is essential to protect data of patients in order to follow the
statutory regulation of public confidence. Patient’s data is most important aspect which is
required to be managed and saved ethically by Health Care Organisation. Thus in NHS
confidential patient information statutory requirement is being adhered in order to provide them
high quality services (Lustgarten,Sinnard and Elchert, 2020). Furthermore it has been identified
that in NHS record keeping plays most important role, as it involves patient journey through
services. This record is further being protected in order to effectively meet the statutory
requirement for retention and disposal of records. The statutory compliance in healthcare is about
adherence of regulations, guidelines, laws and specification in healthcare organisations relevant
to the process of business. It is required by the healthcare organisations to develop effective
policies, procedures and processes to define the proper conduct, train the staff of organisation
and monitor adherence of policies, procedures and processes. It covers numerous areas involving
managed care contracting, patient care, joint commission on accreditation of healthcare
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institutions, billing, reimbursement, etc. In terms with relevant legislation this is one of the most
important statutory requirements for reporting and record keeping is being followed in NHS in
order to provide ethical health services to patients.
Describe the regulatory and inspecting bodies’ requirements for reporting and record keeping in
a care setting
Government of United Kingdom or secondary of state of health has ordered the
organisations in hospitality sector to effectively comply with the requirement of data
management and processes in health and social centres. In terms with record keeping it is
essential to deal with information in confidential and ethical manner. Furthermore, it has been
identified that regulatory and inspecting bodies also states that it is essential that the information
sharing must only undertake place among individual who requires the information. Along with
this healthcare organisation is also required to effectively protect legal and regulatory
requirement and manage level of trust and safety for patients. In context with the present case
scenario it has been identified that record keeping is one of the most important element for health
and life of patient and this must only undertake place with relevant individual. This is one of the
most important forms of regulatory obligation (Iwen, Stiles, and Pentella, 2020). Furthermore it
has been identified that Data Protection Act 1998 is one of the most important regulatory
legislation that aim towards handling and protecting information of patients. In this process
organisation like NHS is required to hold, record, use and disclose information according to the
legislation. The health and social care Act 2008 also states that it is essential for Healthcare
organisations to undertake use of favourable practices in order to record, keep and report data
and abide all the essential laws and regulations expectation of national regulator. The one
inspecting regulatory body needed for reporting and record keeping is Care Quality Commission.
Describe Analyse the implications of non- compliance with legislation, regulating and inspecting
bodies’ requirements
It is essential for organisations within healthcare segment to comply with the guidelines,
laws, regulation and legislations which is related to their business operations. However violation
of these regulatory compliances will lead towards legal punishment as well as federal penalties.
In addition to this it has been identified that non-compliance with inspecting and regulatory
bodies, legislation requirements will lead Healthcare organisations to face penalties and fines
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(Liambila et al., 2020). Along with this, they will also have to face reputational damage,
regulated out of business and lack of consumer loyalty and trust. It has been identified that it is
important for organisation like NHS to maintain safety and quality of care by adhering different
type of compliances and regulations requirements in order to act in ethical manner negligence.
Negligence of this will lead organisations to face number of challenges that may further affect
image of entity in respective sector. In addition to this it has been underlined that loss of
potential or current staff, loss of reputation and imprisonment are also some of the implications
of non-compliance with inspecting, legislation and regulating bodies (Bross, and Krugman,
2020).
Evaluate the consequences of non-compliance with reference to the media, service user safety
and the credibility of the care setting
According to the above mentioned case scenario it has been identified that data record is
playing most important role and negligence of record keeping and reporting may lead
organisation like NHS to face heavy criticism (Kelley and Gilad, 2020). In addition to this it has
been identified that negligence of non-compliance with the reference to service users safety,
media and credibility of care setting will also lead towards endangering lives that will further
impact upon sustainability of organisation. Furthermore it has been identified that non-
compliance of these will also impact upon growth expansion of the organisation which will
further impact upon their licensing in respective sector.
Thus according to the above mentioned analysis it has been identified that there are
number of severe consequence of non-compliance with context to credibility, media and service
users safety which have adverse impact upon long term sustainability and other aspects of
organisation in number of ways such as Media response, Enforcement notices, monetary penalty
notices, or other legal action, own professional credibility, termination of contract, consequences
for the individual e.g. loss of trust in services, loss of dignity, privacy and respect and more
(Hartley, and Elowitz, 2020).
Describe the process of storing of records in own care setting
Storing of records in NHS is an integral component of professional practices and vision
of this healthcare organisation which is to deliver qualitative healthcare services to individual. A
good record keeping management facilitate NHS to continue the care that they are providing to
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