Health and Social Care: Reporting and Record Keeping Requirements

This report, focusing on Core Havencare Ltd., a UK healthcare organization, examines the critical aspects of reporting and record keeping in health and social care services. It begins by outlining statutory requirements, including those from the Health and Social Care Act, and emphasizes the importance of accurate and confidential record-keeping for patient care and legal compliance. The report then details the roles of regulatory bodies, such as the Health and Safety Authority and the Mental Health Commission, and the consequences of non-compliance, including loss of trust and potential legal penalties. Furthermore, it explores the processes of storing records, both paper and electronic, and the importance of sharing information internally and externally, while also considering the internal and external requirements for recording information. The report also addresses the use of technology in recording and reporting, the benefits of involving service users in record-keeping, and concludes with a discussion of managing service user records in compliance with national and local policies and guidelines.

Effective Reporting
and Record keeping
in Health and Social
Care Services

Table of Contents
INTRODUCTION...........................................................................................................................1
TASK 1............................................................................................................................................1
P1. Statutory requirements for reporting and record keeping in own care setting......................1
P2. Regulatory and inspecting bodies’ requirements for reporting and record keeping in a care
setting..........................................................................................................................................2
M1. Analyse the implications of non-compliance with legislation, regulating and inspecting
bodies’ requirements...................................................................................................................3
D1. Evaluate the consequences of non-compliance with reference to the media, service user
safety and the credibility of the care setting................................................................................3
TASK 2............................................................................................................................................4
P3. Process of storing of records in own care setting.................................................................4
P4 Reasons for sharing information within own setting and with external bodies.....................4
P5 Illustrate the internal and external requirements for recording information..........................5
M2. Examine the current processes in own care setting related to storing and sharing records.6
D2. Evaluate own work settings arrangements and processes for storing and sharing
information, making recommendations for improvement..........................................................6
Part 2................................................................................................................................................7
Lo 3..................................................................................................................................................7
P6 How technology is used in recording and reporting in own care setting...............................7
P7 Benefits of involving service users in record keeping processes...........................................8
P8 Accurate, legible, concise and coherent records regarding service user care for different
service users following own settings guidelines.......................................................................10
P9 Different aspects of own management of service user records with reference to compliance
with national and local policies and guidelines.........................................................................11
Conclusion.....................................................................................................................................12
REFERENCES..............................................................................................................................13

INTRODUCTION
In every organisation reporting and record keeping is essential. It is considered as the
process of recording events as well as transactions. It is an crucial aspects of health and social
care services. Effectual record keeping is helpful to promote patient care as well as better
communication (Fleissig and et.al., 2017). It is a product of effectual teamwork and techniques
for creating standard quality heath and social care services. For this report, the chosen company
is Core Havencare Ltd. Which is a healthcare organisation in UK. The purpose of this report is
to explain the statutory requirements for reporting and record keeping. Regulatory and inspecting
bodies requirements and process of storing records. Reasons for sharing information with
external bodies and internal as well as external requirements for recording information.
Technology is utilise in recording and reporting in firm. Benefits of involving service user in
recording keeping methods and records are produce in respect of service user care. Apart from
this different aspects of own service management users records with references to compliance
with national and local policies as well as guidelines are also mentioned in this report.
TASK 1
P1. Statutory requirements for reporting and record keeping in own care setting
Reporting and record keeping is essential for both patients as well as for healthcare firm.
While maintaining relevant and accurate records company can facilitate better quality of services
to their employees and patients. In health and social care, reports and records are kept with the
use medical record numbering, dividers, folders and so on. For this there are requirements of
statutory. It imply treating record keeping as a total system which is planned, organised,
reviewed and developed as whole.
The statutory requirements for keeping records are set in regulations 20 of Health and
social care Act. So, its requirements in Core Havencare Ltd. are as follows:
Care records:
Care services must be capable to show that keep records of care and treatment are
facilitated to all services user. In Core Havencare Ltd. All records regarding service users, care
and treatment through their mouth words , telephone calls etc. Recording are link in confidential
way, data about individuals which relates to their care from another professionals. For all this
freedom of information act 2000, general data protection regulations 2018 and human rigths

1998 are required by respective firm. All this help Core Havencare Ltd. to access the recorded
data that is held through public sector company, to safe most vulnerable in societies considering
individuals receiving care as well as support etc.
Access to records:
Records are available to service user or legal representative concerned care and
treatment. For example: someone lacks mental capability to make decision on Core Havencare
Ltd. And employees. Thus, all should have knowledge about where records and reports are kept
and to access them (Dziegielewski, 2018). Therefore, any request to view a individual records
are addressed with reference to needs of general data protection act 1998. through this Core
Havencare Ltd. Can secure their records of patients and employees. Also, identify the data that
are stored by government and another firm about them.
P2. Regulatory and inspecting bodies’ requirements for reporting and record keeping in a care
setting
Regulatory and inspecting bodies are considered as government agency which is
established to perform a regulatory functions. Many regulatory bodies protect public from
various health risk and facilitate numerous events for people health and welfare. Some
regulatory body in health and social services are heath and safety authority, mental health
commission, medical council and so on. Some are mentioned below:
Health and safety Authority
Health and safety Authority is refer as a statutory body that is accountable for regulating
health and social care in workplace like health care premises. In Core Havencare Ltd. This
regulatory bodies is required to plan the process for accident and health protection, to line up the
duties of management, to develop, execute, review and maintain policies for health and safety.
Mental health commission:
This regulatory bodies facilitates a safeguard for individuals stay in hospital under
mental health act powers. In Core Havencare Ltd. It is required to promote, motivate and foster
the set up as well as maintenance of better and standard practices for the delivering services to
mental health care and also take whole sensible steps for securing individual interest detained.
Failure to comply enforcement notice:
Enforcement notice is considered as a formal document which creditor issue to debtors,
providing warning about taking action to cover owed money. If Core Havencare Ltd. Failure to

comply enforcement notice in that case notice of prosecution should generally obey. Legal action
may also fail if notice is not served appropriately, not complied and so on. Also, court
conviction can be obeyed under section 42 of HSWA this order the individuals to follow steps
towards remedy.
Failure to comply legal action:
This is refers as a process of enforcing a country law through proceedings in system of
court (Cameron and Lart, 2013). If Core Havencare Ltd. Fail top comply this then they certain
penalty are to be imposed in case of illegal activities happenings, may imprisoned in jail and so
on.
Due to this some consequences happens in Core Havencare Ltd. such as loss of trust, dignity,
privacy etc. that are mentioned below:
Loss of trust: In health care, there is risk as well as uncertainty for patients. Trust is
essential in this sectors. Therefore, if Core Havencare Ltd. Fail to follow legal regulation then
few unwanted actions are incurred by government which impact trust of individuals negatively.
Loss of dignity: In health and social care, dignity refers as a types of care, into setting
that promotes and supports as well as do not weaken a individuals self respect irrespective of any
variation. If Core Havencare Ltd. Remove legal ethics and rights from their services, any illegal
activities are functioning, do not respect others then individuals losses their dignity.
M1. Analyse the implications of non-compliance with legislation, regulating and inspecting
bodies’ requirements
The implication of non compliance with legislation, regulating and inspecting bodies
requirements in Core Havencare Ltd. Are loss of trust, loss of dignity, certain penalty are
imposed, effects the reputation of company and so on.
D1. Evaluate the consequences of non-compliance with reference to the media, service user
safety and the credibility of the care setting
Consequences of non compliances in Core Havencare Ltd. Are some penalties imposed
on them, it gives negative impacts to their patients, diminish the firm credibility and their
relations with stakeholders, risk of disciplinary and so on.

TASK 2
P3. Process of storing of records in own care setting
In health and social care records are stored as it facilitates the relevant as well as exact
information about patients details, treatments that is given to them and so on. Process for storing
paper documents like clinical notes, incident report etc. In Core Havencare Ltd. Records are
store through following process:
 At first the forms are obtained
 Reports are started
 Basic facts are facilitated
 Involve line regarding nature of incidents
Process for storing patient information in Core Havencare Ltd. Are as follows:
Care plans: Through this respective company can analyse the patients requirements,
plans for meeting their needs.
Nutrition recording: Through this process Core Havencare Ltd. Can know about the
patients growth, diseases, health of organism.
Process of maintaining confidentiality in Core Havencare Ltd. Are: files of people are locked
and secured, data are not told to anyone, patients medical, details are not explained without its
consent
P4 Reasons for sharing information within own setting and with external bodies
This is very important for the health care providers to secure the data and the information
of the patients and these data should not be shared with any other third party without the
information of the patients (Sibbald, Shen and McBride, 2014). Whereas sharing the information
for treatment of the patient is considered as one of the main aim which helps in providing better
treatment to patients. Here the information may be shared within the own setting so that better
option to treat the patient can be discovered. The doctors or the staff should take the consent
from the user of the service or form their advocates which would provide the acceptance on
behalf of the patient if patient is not able to talk or unable to understand the requirements of
giving consent.
Also if the doctors shares the information without the consent of the patient then they
may face various implication which are set in the law and this would be known as breach of right

to privacy of the user. Here the implications that are defined in the law includes the
imprisonment and the monetary penalty.
The doctors are required to carry on the reports to the other professionals so that they are
able to achieve the objective of treating the patients in better way. This would help them to have
a better treatment and would also help the patients to be cured as early as possible.
The information that has to be shared to the external bodies includes that hospital should
share the information in the secure and proper manner so that information is not shared with the
third party while in transit. These information should be shared securely through the electronic
forms having the security which is accessible by the end user.
P5 Illustrate the internal and external requirements for recording information
Recording of data of patients, employees, etc. at Core Havencare Ltd. can be done with
the help of some sources. As there are many departments in Core Havencare Ltd., so with these
resources data can be handled with care. There is requirement of internal as well as external
recording requirements which helps to maintain proper records of related parties of Core
Havencare Ltd.
Internal recording requirements:
Medical history- Medical history of employees and patients is important and relevant
because this provides knowledge about their demands and hence better services can be provided
(Care Quality Commission, 2012). If there is specific health issue to client, then they will give
diet accordingly. So medical history helps in keeping records of informations related to clients.
Test and treatments- There are different types of test such as ECG, Anaesthetics , etc.
which helps to get information about medical background of consumers. With the help of these
test information about treatment to consumer can be analysed. This is the basic requirement for
recording information because this helps to provide information about routine of candidate.
Medical management plan- Medical management plan is also internal requirement of
candidate as it helps to provide information about health information of consumers and
employees of Core Havencare Ltd. Medical management plan is official document which is
maintained by management of Core Havencare Ltd. In order to provide best services to
consumers and employees.
Service user form- Service user form is filled by consumers who are availing services
from Core Havencare Ltd. Health care sector. This is internal source which helps to provide

information about personal, basic , health related information of consumers. Hence with this
form, it is easy to carry complete information about clients.
External recording requirements:
There are different acts which are farmed under legal legislations which helps to provide
information about change in plans and policies. There are some acts such as he Health and
Safety at Work, etc. Act (1974), Management of Health and Safety at Work Regulations (1999),
etc. Some of the acts are discussed as under-
Management of Health and Safety at Work Regulations (1999)- As per this law, there is
requirement of proper policies at Core Havencare Ltd. through which they complete
implementation of proper policies for risk assessment at work place activities. Hence there is
proper arrangements related to discharging of employees, proper procedure to deal with serious
issues (Anderson and et.al., 2012).
Reporting of Injuries,
Diseases and Dangerous Occurrences Regulations (1995)- As per this law, it is responsibility
of managers of Core Havencare Ltd. To proper plan strategies through which incidents at
premises can be controlled. Under this proper recording of accidents, injuries or work related
death is recorded so it is clear to make proper recording of information.
Workplace (Health, Safety and Welfare) Regulations
(1992)- As per this act, there are some basic regulations related to accommodations at work
place. In health care organisation Core Havencare Ltd. In case of improper premises , mangers
are punishable under this act. Hence this is also reliable way to complete information about
premises.
M2. Examine the current processes in own care setting related to storing and sharing records
In Core Havencare Ltd. Process for storing and sharing records by obtaining the forms,
initiating reports, basic facts are facilitating, involving line in respects of incidents nature. All
these are records and shared in both paper as well as electronic forms.
D2. Evaluate own work settings arrangements and processes for storing and sharing information,
making recommendations for improvement
All the process can be stored and shared in electronic forms with considering the data
protection. Through this whole data are secured within Core Havencare Ltd. Also, the process
can be more modified and arrangements are sets effectively.

Part 2
Lo 3
P6 How technology is used in recording and reporting in own care setting.
A record is considered as the permanent written communication that is done so as to
capture the relevant information about the health care and management. It is seen that the record
keeping in the health and social care department is one of the main task so that the records of the
customers are maintained and nourished for the future use. It is the principal repository for
acquiring the information which concerns a patients health care (Ziviani, J. and et.al., 2014). The
term health care technology is a broad term which helps in describing the technology and the
infrastructure which should be used to record or analyse the patients health care data. These
technology includes the health record systems which includes the personal, paper and electric
forms. Also personal health tools including the smart devices and the apps that should be taken
care of while performing the task of recording the data of the customers and the clients. This
helps the practitioners to check the data which is required for the application of the professional
service so as to improve the health of the patient.
As now a days the health care centres are using the health information technology which
helps in improving the care and also increases the outcomes so that the older adults are able to
grow the programme of research that is propelled by the recent transformative policies. The basic
structure of electronic health record help the organisation to have a automated health records of
the patients with the help of which they are identify the patients and found the prescriptions that
were given to them. Also this helps to recall the laboratory test that were done of the patients.
It is seen that the electronic health record is not considered as simple replacement of the
paper records but it can identify the problems that are not taken care of due to the paper records.
As the paper record are considered as the documents that have various problems that are
identified, some of which includes privacy and the confidentiality issue which would be
addressed if the electronic form of data is maintained. As it is seen that in number of years the
the term has been used to describe the move from the manual to the electronically generated
form. Hence various types of technology that is used while setting the health care organisation
includes the following:

 Automated health records: This is the technology is used to describe the collection of the
computer based stored images as compared to the traditional recording of the documents.
In this technology the documents are scanned into a computer and the images are stored
on the optical disks. This helps the health care organisation to access the space and
control the problems that are related to paper records. This does not includes the input or
the output of the patients care level which is the issue related to this technology.
 Computer based records: The term computer based record means that collection of the
data of patients. This helps in providing the integrated data on a patients registration. This
also collects the patients financial information so that the treatment can be done
accordingly. Although this form of computer based patients record helps in implementing
the variety of settings so that faster and quick treatment can be given to the patients.
The organisation can use the smartphone application so that the patients are able to apply
for the meeting with the doctor (Stathopoulou, 2017). These can be developed in a way that if
user enters its name and mobile number than all the information is shown on the mobile app.
This helps the patients to have the information on the mobile phone. Also the patients can check
the reports and the prescriptions which are given by the doctor. Also this helps to get the
knowledge of the things that are required to be eaten and are not required to be taken. Also this
would help to get the consultation from the doctor virtually without going to the doctors clinic.
While maintaining the data on the computerised record it is utmost important for them to
protect the data from being leaked. Hence various Java scripts should be used so as to protect the
data from being leaked. The software should be used in a way that it is only accessible by the
patient with his or her identity. This would help in securing the data of the customer ethically.
Through these processes the recording and reporting of the clients information can be
done which would be kept for the eternity on the server of the hospitals and it would also help
the patients to not to keep the records in the paper format which is very difficult for them.
P7 Benefits of involving service users in record keeping processes.
The term involving people in the own health care means supporting the managers to
manage their own health and well being on the daily basis. This means supporting the patients in
being involved in deciding about their care and the helping them ion choice and control over the
NHS service that they would receive. This means that focusing on the matters which are related
to the patients life. This means that providing the commissioning service that helps the

individuals to have the information and the care and support that they requires. There are
different ways that helps in involving the people in their own health and care. These ways
includes:
 Personalised care and support planning: this is the way that helps the organisation and
the patients to have a systematic way so as to ensure that individuals living with one or
more long term diseases are supported through proactive conservations. These should
focus on what are the things that matters most to the patients (Moriarty, Manthorpe,
Stevens and Hussein, 2015). There should be process of sharing the information and
identifying the medical and non medical needs and documenting the information on
behalf of the patients so that proper treatment can be given to them. This should also
include the house of care approach where the work has to be done so that they are able to
provide patient a support while at their home.
 Shared decision making: Here the patients and the organisation are required to provide
a shared decision making where the people who experience the change in their health
work together with the clinicians so as to select the tests, treatments or support the
packages. In any of the decision where there is more than one options, this should include
values and the preferences of the person and the risk attitude that are related to it. This
would be important as the clinical evidence in choosing which of the option should be
followed.
 Improved communication and the information sharing: This is one the best way
which helps in sharing the information which is related to the patients health information
sharing process. Communication skills are especially important in a hospital setting,
which patients often perceive as more impersonal than a visit to their primary care
physician’s office. While communicating with the patients it would help in achieving the
objective of knowing the problems that are faced by patients in their daily life through
which the medical practitioner would be able to know about the treatments that should be
given to the patients.
Also there are certain benefits that are related to the involvement of care users. These
includes various benefits which means:

 Involvement of patients can ameliorate the attribute of public health acts. For example,
diligent with long-term unwellness often have show about their inattention that upbeat
care cater and policy makers lack.
 Users and carers may not have the aforesaid conflicts of interest as medical professionals
and policy makers.
 User engagement admit people’s capability for self-determination, furnishing them with a
say in the preparation of their care. The WHO Declaration of Alma Ata states that
“people have a right and duty to take part separately and jointly in the preparation and
execution of their health care”
 In a setting of prioritised and distributed health care services (like the NHS), considering
users and carers in service planning can encourage:
 Participatory Democracy
 Public Accountability
 Transparency
P8 Accurate, legible, concise and coherent records regarding service user care for different
service users following own settings guidelines
In health care organisation Core Havencare Ltd., there are different aspects which has to
be considered to provide proper health care services to consumers. With maintaining proper
records regrading consumers, it is easy to make plans for better consumer satisfaction. When
records at Core Havencare Ltd. are kept in concise, reliable manner then this is time saving
approach for doctors as well as managers. When records are kept in authentic and reliable
manner, it is easy to decide about medication and care of client. While keeping records, there
must be some points which has to be considered. Some of them are as under-
Features of effective recording- Records related to service user at Core Havencare Ltd.
Are up to date. In case of recovery of client, it must be recorded by doctors. Information must be
complete, time bound and accurate (Acker and Lawrence, 2019). This makes information clear
and concise. For example, if a doctor is providing health care service to patients then its is
compulsory that the individual should up to date with the patients health, have complete and
accurate information about them and their daily routine. So that when the doctor is not available
then another doctor can monitor the records and provide services according the information or
records.

Types of record keeping- There must be proper recording of data in the form of proper
schedule, rotas, minutes of tests, etc. It is essential for Core Havencare Ltd. to maintain
nutritional status required according to demand of consumers. There must be proper recording
regarding progress rate in improvement of consumer's health. For instant, during the the time of
offering services to patients, the doctor should maintained the records of them in time sheets and
rotas. The person should mentioned all the information in the records which is discussed in the
meeting regarding patient. The doctor also described the nutritional status of the patient and if
there are any kind of changes are make regarding health and treatment, they should also defined
in the records. It will be helpful to provide accurate information about the service taker to doctor.
P9 Different aspects of own management of service user records with reference to compliance
with national and local policies and guidelines
Management within organisation refers to proper planning, recording, organising
business operations. With proper management, it is easy to make changes in business operations
which is relevant and significant to keep client satisfied and offer them best services. Hence there
are some legal laws which has to be considered while recording data related to client. These
guidelines must be clear to staff, so they are aware about way in which recording of information
must be done. With change in geographical region, there is difference in policies and guidelines
of country. There are some measures which has to be considered by managers of Core Havencare
Ltd. in order to compile with local and national policies. Some of them are discussed as under-
Using numeracy skills: There must be recording information about clients in numerical
manner. There are many activities in day to day operations which has to be record in numeracy
manner, because this is more effective and reliable to analyse outcomes. Numerical data is more
effective in managing business operations.
Day to day administration and management of records- In Core Havencare Ltd., the
doctor should have proper day to day records and manage or administrate them. So they have
accurate information and during the time of necessity they can track the record of them.
Recording of nutritional values- In health care organisation Core Havencare Ltd., there
are patients who need to give nutritions which helps to recover their issues. Hence when
information is collected regarding nutritious terms, then positive impact on sales can be analysed
(LaFromboise, 2018). There is requirement of different nutritions as per health of patient, so it is

easy to get provide to clients which helps in proper management of activities within Core
Havencare Ltd.
Monitoring routine activities- There are many activities which has to be considered by
managers of Core Havencare Ltd. While conducting day to day activities. It is important to
monitor activities to get better outcome. When management of Core Havencare Ltd. takes care
about outcome of return then they are able to achieve objectives and growth of organisation is
possible.
There are various local and national policies, plans and strategies are consider when
producing accurate, concise and legible documents like universal coverage, people centred care,
emphasis on public health and health in all policies. For example, In UK, there various plans and
polices which are running by the government such as green belt, planning and noise archaeology
and planning etc.
Conclusion
From the above report it is concluded that, health and medical care reporting and
recording is one of the main process which helps in keeping the record of the patients
information. There are various ways that are included in providing the information of the service
users. As there are various legal and regulatory aspects which are used for reporting and record
keeping in the care setting which the medical practitioners should take care. Also there are
various requirements which helps in future regarding the requirements. Also it is seen that there
are various technology that are used in the process of recording and reporting various care
settings.

REFERENCES
Books and journals