Unit 17: Reporting and Record-keeping in Social Care

This report examines the critical aspects of effective reporting and record-keeping within health and social care settings. It begins by describing the legal and regulatory frameworks, including statutory requirements and the roles of inspecting bodies like the CQC, emphasizing the importance of accurate and confidential record-keeping. The report details the legal requirements, such as the Health and Social Care Act 2008, and the significance of data protection acts like GDPR and the Data Protection Act 1998. It discusses the Caldicott principles, the Freedom of Information Act 2000, and the role of the Care Quality Commission in ensuring compliance and patient rights. The report also explores both the internal and external record requirements, detailing the types of records used and the importance of secure storage and information sharing, adhering to policies and legislation like the Data Protection Act 2018, GDPR, Human Rights Act, and MCA, emphasizing the necessity of prompt responses and the protection of patient data.

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

manager has to report to higher authority.
The Caldicott report and principle 1997: The key significant focus associated with this report
is to effectively review how the information associated with the patient has been reviewed with
the health and care setting (Fife and Eckert, 2017).
Principle 1: Providing appropriate reason for appropriately using the key sensitive information.
Principle 2: The sensitive personal data must be used where it is of key relevance importance.
Principle 3: The confidential information of the individual is considered to be very essential. It
is very important to use that much private information required.
Principle 4: It is significant that admission to the private information is restricted and only the
professional must have access to such patient data.
Principle 5: the information associated with the patient must be safe and secure which helps in
protecting the privacy of the patient.
Principle 6: The usage of the personal information is considered to be highly legal and the health
care department must focus on managing the confidential data of the person which in turn helps
in complying with the legal requirement.
Principle 7: The responsibility associated with the exchange of the data must be considered to be
highly relevant which helps in acting in a responsible manner in order to guard the patient's
privacy.
The freedom of information act, 2000 is highly significant in providing access to the
information which has been held publicly. This act also tends to include records which has been
by the government body which tends to include areas which are located by the government
across UK. It is very significant in protecting the data which in turn has been stored by the public
bodies of Scotland. The key relevant documented materials mainly comprise of the electronic
files, written papers, notes, images, emails, video, etc. The relevant principle linked with the
freedom of information law is that, people have appropriate degree of right to examine about the
key activities of the public (Florence, 2016). Every individual has the right to gain access to the
official set of information and only those informations must be kept private which are highly
confidential. The request for gaining access to the information must be treated fairly.
Care quality commission inspecting and regulatory body: This is considered to be as one of
the key significant measure which helps in complying with the specific rights within the care

setting. It is usually based on the appropriate set of rights which helps in assuming the specific
succeeding norms. The health care setting must always focus on complying with providing the
specific level of care which helps in meeting the specific needs and requirements. The patient
must always be treated with utmost degree of respect and dignity. Every individual has to be
treated equally (Tanwar, Parekh and Evans, 2020). This way it helps the management of the
company in ensuring that the needs and wants of the person has been protected. Any individual
who has been working legitimately on the patient's behalf. Proper consent must be taken before
providing any care or medication to the patient. The management of the company must
effectively focus on ensuring that appropriate degree of safety must be maintained associated
with the record and report keeping within the care setting. It is useful in recognizing the health
and safety risk associated with the patient. It helps in providing effective care service which in
turn is not threatening or dangerous to the health of patient.
The report is talking about how reporting is effective in health and social care and
regulatory, policies and ethical guidelines to follow in order the requirements related to keeping
recording accurately. Moreover, all aspects of information are used when is followed the law will
be more
easier to minimise the errors.
Exploring the external and internal record requirements associated with the care setting.
Therefore, the new carers need to know about the compliant procedures with health and social
care setting because will gain knowledge about legislation and protocols and all those
requirements set in place. Is important to have information about all service users in any aspects
of life like physical and mental wellbeing because will be stored securely. Internal and external
requirements is compulsory to record all information on electronic documents or paper, but this
is up to organisation choice. Electronic documents include recording care plan, medicines,
nutrition and prescribing tests. Some of health records used in care home: charts notes, history of
patients, referrals, consultations letters and medical report.
Internally requirements: -corespondence, clinical forms and medication lists. (ICO,2017)
Is everyone responsibility when provide care to observe accountability when producing records
and information of patient and must to meet the legal requirements in store records of the patient.
(Walsh and Antony, 2007). In this context includes as well that any concern must be addressed
and report to manager to help with guidance.

Storing of records
Everyone providing care have a legal duty to keep information confidential, the organisation
must be comply with care records policies which sets out the rules how patient information is
used or who have access to this, the GPDR is responsible for protecting the confidentiality of
patients and give appropriate and lawful information sharing. That’s why is important when you
storing the medical papers to be in secure place according to care setting procedures and policies.
In own workplace we have restrictive access like cabinet has a lock on it and the office has key
code for entrance, then the records are kept in secure storage location like all the medical records
stored or the medication to be stored out of sight of unauthorised patient and locked in safe place
when is not supervised. When the handover is taking place and is discussed about the
information relating patient care then it should take precaution to ensure no one can hear the
conversation. Addition to this, Using secure systems for the recording, storing and sharing
of information is essential in health and social care setting. records should be stored in
computer system and access restricted by using the personal password when need to access the
information need, also do not
share the password with others and always logging out from system. The records must be on the
hard drive of computer or on secure server. Basically, this is organisation`s policy to encrypt
files when they transfer data to other devices for extra security.
Sharing information
Is very important to share right information at right time and with right people because is good
practice to safeguard patients from any abuse, as working in accordance with policies when
sharing personal information between own setting and other bodies (GP. the police, services
providers, regulators) for safeguard reason. The data protection act 2018, GPDR, The Human
Rights Act and MCA all this are in contact to safeguard the patient if there is any concern risk of
abuse, neglect then the duty of care setting is to communicate with external bodies to solve the
case in sensitive matter by follow the law.
Sharing information response
The response time associated with gaining access to the information is of key relevance
importance. This is useful in promoting of the critical protection of the key relevant data. The
response time must be quick because it helps in resolving disparities. It must focus on

emphasizing on effectively decreasing the response time and helps in increasing the
coordination, collaboration and effective use of the shared information.
Reason for sharing information with external bodies and others
The sharing of the data is considered to be as highly crucial because it is useful in providing the
best possible healthcare services. The healthcare records has been increasingly stored in the
electronic format (Agniel, Kohane and Weber, 2018). The external bodies helps in gaining
relevant degree of information which can be effectively accessed on the public basis. Information
sharing with the internal bodies within the healthcare setting is useful in providing the best
possible service associated with the care and leads to better results and outcomes. It is significant
in detecting key relevant issues and helps in effectively responding to the development of a
disease and provide with the best treatment.
Precautions to be taken in mind while sharing information
There should not be any over- exposure at the time of sharing information. The data must
be encrypted in order to provide them with the better degree of security and helps in ensuring the
safety and privacy at the time of information sharing. The management of the healthcare setting
must significantly comply with the general data protection regulation act which helps in
protecting all the key relevant information (Tanwar, Parekh and Evans, 2020). Drafting up of the
tight policies and the procedures helps in effective handling of the patient information.
Complying with the health information privacy law and other regulations to protect the private
information.
External and internal requirements
Recording requirements to keep the information safe is make compulsory to record it on
electronic documents, the record management NHS code of practice 2006 gives policies for
health professionals to have a record for all patients. In regard, I will mention that in own care
setting is demographic internal requirement about patient getting care. There are several tools in
used for available options to fulfil the reports in appropriate manner. External requirements are
laid out in regulatory and legal aspect. There is a responsible record keeper for answering to
parliament, and the manager of care setting to observe all shared information between bodies.
Requlatory requirements provide that a lack of agreement go to punishment. AS is saying above,
the lack of record keeping is happening when the staff is not pay attention to records, however, a
scrupulous record keeping may help the patient in a court

of law to defend their clinical records. As a result, communication, responsibility, inquiry and
neglecting is other tool that are protected by law.
Today, in health and social care sector, such types of approaches is increased by adopting good
quality of care but also the sharing of information are kept confidential following the
requirements settled by laws. In this context, delivering care and storage the information become
the most important part of record keeping in all care settings.
CONCLUSION
Record keeping and reporting is useful because it helps in promoting the patient care and
leads to effective communication. The good record keeping helps in effectively developing high
degree of quality workforce and helps in reinforcing professionalism. Complying with the legal
laws and legislations is of key importance.

REFERENCES
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no. 3, pp. 17-21. Griffith, R. and Tengnah, C. (2010) 'The Health and Social Care Act 2008',
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journal of community nursing, vol. 15, no. 12, pp. 598-602. ICO (2017) The Guide to Freedom
of
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information/ [13 December 2019]. ICO.org (2018) Data sharing code of practice, [Online],
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https://ico.org.uk/media/2615361/data-sharing-code-for-public-consultation.pdf [13 December
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