Unit 17: Effective Reporting and Record-keeping in Health and Social Care Services
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Added on 2021-04-05
Unit 17: Effective Reporting and Record-keeping in Health and Social Care Services
Added on 2021-04-05
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Unit 17:Effective Reporting and Record-keeping in Health and Social Care ServicesSophie KeemsS0246059Word count: 35001 | P a g e
Table of ContentsIntroduction...............................................................................................................................3P1 Describe the statutory requirements for reporting and record-keeping in own care setting....................................................................................................................................................3P2 Describe the regulatory and inspecting bodies’ requirements for reporting and record-keeping in a care setting............................................................................................................5M1 Analyse the implications of non-compliance with legislation, regulating and inspecting bodies’ requirements.................................................................................................................7D1 Evaluate the consequences of non-compliance concerning the media, service user safety and the credibility of the care setting........................................................................................8P3 Describe the process of storing of records in their own care setting...................................9P4 Explain the reasons for sharing information within its own setting and with external bodies.......................................................................................................................................10P5 Accurately illustrates the internal and external requirements for recording information in own care setting.......................................................................................................................11M2 Examine the current processes in own care setting related to storing and sharing records..................................................................................................................................................11D2 Evaluate own work setting’s arrangements and processes for storing and sharing information, making recommendations for improvement.....................................................12Conclusion................................................................................................................................13References................................................................................................................................142 | P a g e
IntroductionThe health care processes a large amount of data, and so this information must be recordedand kept safe for reference. Effective reporting and record-keeping in health and social Careempower patients by putting them in control of their experience of their health. Recordkeeping in health also delivers integrated patient care breaking down geographical,professional, and institutional boundaries.Effective reporting and Recordkeeping are anessential activity to care service because it prevents patients from repeating the sameinformation to many professionals which are found to be one of the greatest frustrations forservice users. Over the years, effective reporting and record-keeping have ensured andimproved patient safety by preventing gaps and mistakes in patient’s history record in termsof treatment. Record keeping in health and social care has caused a positive impact intreatment by enabling self-management care for patients that are recovering from an acutecondition. Patients share their health information with their clinicians whenever they visitthe health centre throughout their lives, therefore recording this information and using it toimprove people’s health is useful to medicine. These recorded data from various health careinstitution and geographic locations present a significant advantage in innovative, efficient,and cost-effective research thus informs decisions in clinical medicine, health serviceplanning and public health. Governments and other health agencies have legalised andprioritised the use of routinely recording health data as tools to improve patients care,transform health research, and improve health care efficiency (Coster C et al.,2006). Thisreport illustrates legal and regulatory aspects in record keeping in health care, it furtherexplains how technology has brought positive impact in record keeping. This report alsodemonstrates how record can be kept and maintain national and local policies.P1 Describe the statutory requirements for reporting and record-keeping in own caresettingThere are three legislation governing access to patient health record: The Data ProtectionAct 1998. The access to health records Act 1990, and the Medical reports Act 1998. The firstgoverns the right of living individuals and authorised persons, the second governs access todeceased patients’ records, and the third governs the right for individuals to access reportsrelating to themselves provided by medical practitioners for employment or insurance3 | P a g e
purposes. Access to this legislation is limited to protects patients’ records. Also, records canbe limited to patients if it could cause harm to the patients mental or physical health.Parents have the right to access their children health records, but their confidentiality mustbe checked as well. (Dubovitskaya, Xu, Ryu, Schumacher, & Wang, 2017). Providing anaccurate, timely, relevant clinical record that ensures the safety and coordinates care thatinvolves the patient, carer and family are especially important in health care. Clinical andadministrative staff contributing to a patient must provide an accurate health record whichcan be used to determine clinical decision making, improve patient care through clearcommunication of the assessment and treatment and care planning rational. There areseveral statutory requirements in reporting and record-keeping in my own specialist area inmy own health and care setting. All information recorded must be up to date with everyinformation their patient may share with them. This information must be kept safe andmust be easy to access them for future use. (Archenaa & Anita, 2015). Health practitionersare accountable for ensuring that they are capable and aware of and knows how to use aninformation system, for example, using an electronic patient record system and medicaldevices in accordance. Written data must be readable, legible, and written in black ink toenable photocopying or scanning of documents; signed and be kept safe in a file if required.The records must be maintained and kept in a way that it can be transferred to otherclinicians’ institutions in case of emergencies. There are situations whereby patients maylack their mental capacity to answer their own medical records and are not capable ofmaking decisions at that moment. It is therefore essential to record any risks identified orproblems that may have risen and that taken to rectify them if another episode occurs inthe future. Care records have been introduced to enable sharing of essential informationabout a patient, such as medication, allergies, and adverse reactions. However, any requiredinformation of a patient must abide by the law by following the Data Protection Act 1998.(Wager, Lee, & Glaser, 2017). Every legal requirement and local policies concerning theconfidentiality of health records must always be governed. Health records taken in a formmedia must be kept securely in lockable trolleys to avoid leaked information. Also, recordsmust be continuously updated; this is important in terms of treatment. All recordedinformation must be timed, dated, and always signed. (Walton III, 2016).4 | P a g e
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