Effective Reporting and Record-keeping in Health and Social Care

This report provides a detailed analysis of effective reporting and record-keeping practices within health and social care services. It begins by outlining the statutory requirements for reporting and record-keeping, including data protection policies and confidentiality. The report examines the roles of regulatory and inspecting bodies, the implications of non-compliance, and the consequences for service user safety and the credibility of care settings. It also describes the processes for storing and sharing records, both internally and externally, and evaluates current practices, making recommendations for improvement. Furthermore, the report explores the use of technology in recording and reporting, assesses its benefits, and evaluates its effectiveness in meeting service user needs while maintaining confidentiality. Finally, the report addresses the process of maintaining records, identifying potential difficulties, and evaluating the effectiveness of documentation in meeting service user needs and ensuring appropriate care and reporting are carried out. The report emphasizes the importance of ethical data management, patient safety, and compliance with relevant legislation and guidelines.

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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individuals in ethical manner (Warren, 2020). In order to enable good care and record keeping,
positive exam finding, pertinent negative exam findings, Key abnormal test findings are some of
the most important process to store records. In addition to this process further continuous with
diagnosis or impression clear management plan along with agreed action details of treatment and
future treatment, Clear management plan and agreed actions, Treatment details and future
treatment recommendations and Medication administered, prescribed or renewed and any drug
allergies. Furthermore, Written (or oral) instructions and/or educational information given to the
patient. This process continues with clear documentation and justification for status and ceiling
of cares, communication with patient friend’s family and lastly recommended return visit date is
being provided. Furthermore, it has been underlined that in NHS each and every record is signed
by the person making the entry under compliance with all the record keeping measures.
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
The most important reason of sharing information within own setting and with internal
bodies is to deliver more efficient services with the help of proper coordination, promoting
welfare for wider public protection and stimulate innovation and growth. However it has been
identified that according to the given case scenario it is essential for new staff to have proper
knowledge of the material compliance is associated with health and social care setting and has
proper awareness of the legislation and protocols in order to have understanding related to the
requirements of internal and external recording (Vinic and et. al., 2020). In addition to this it is
essential to provide every essential information’s to family members as negligence of this lead
towards lack of compliance with the law underlined in NHS care setting. In context with record
management and NHS code of practice 2006 that states that it is essential for health and social
care individual to have proper record of individual which is an internal requirement in care
setting. Filing of electronic documents is also required to make such as medicines care plans,
documents, nutrition and prescribed test. While in terms with external requirement of record
keeping it emphasizes upon legal and regulatory requirements. According to public records act
2005 it is essential for in Healthcare organisation to effectively keep records save in order to
answerable to the management of Healthcare and Parliament (Managa, 2020).
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Across the health care organisations, it is very important to share information in order to
provide proper care to the patient. It is significant as it can have profound impact on the life of
people. The relevant personal information or data can be share lawfully it is to keep the
individual at risk safe from mental, emotional and physical harm and if sharing of information
protecting their mental, emotional and physical well being. Apart from this, for safeguarding the
people at risk, sharing of information is very important.
Examine the current processes in own care setting related to storing and sharing records
NHS maintains data record of every individual who uses their services. However it is
essential for a Healthcare organisation to maintain confidentiality of individual by keeping their
data save and share the same with concerned authorities. In context with this organisation it has
been identified, that in order to store and share records NHS undertake use of NHS digital which
is the National Information and Technology partner of this care system. It effectively collect,
publish and processes information as well as data from health care system in England. Along
with this, this information is kept in secure an appropriate manner. While along with this in order
to maintain individual confidentiality and share information with concerned authorities and avoid
abuse of public trust NHS undertake use of tech health are staff, National Data guardian in this
NHS provide advice to professionals in order to keep Health Care information with proper
security (Mytton, Bedford, Condon, and Jackson, 2020).
Evaluate own work setting's arrangements and processes for storing and sharing information,
making recommendations for improvement
In health and social care sector, information sharing is internal part for the practitioners.
The decisions regarding how much information to be shared with others can have profound
influence on the lives of individual. It helps in make sure that people receive appropriate services
at right time as well as prevents the requirement of becoming acute and difficult to mitigate.
Sharing the information between organisations and practitioners is significant for effective
determination, evaluation, risk management as well as service provision. While storing and
sharing information, the general data protection regulation and the data protection Act 2018 must
be followed. The health care professionals should have due regard to data protection principles
that enable them to share personal information. Apart from this, for storing the information,
encryptions must be used. Be honest and open with the people from outset regarding what, why,
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how and with whom data and information will share and seek their agreement while sharing the
information is important.
Why do you think the public is concerned about reporting, recordkeeping and
do you think their concerns are ‘real’?
In the provinces of United Kingdom it is essential for Healthcare organisations and
medical professionals to manage, keep, store and safe information’s and data of patients that has
been gathered by them. It is one of the most important laws which are required to become abide
by all the organisations conducting their operations in Healthcare sector. In this organisations
like Woodland Nursing Home (WNH) must adhered legislations imposed by government of
United Kingdom upon healthcare organisations in order to provide assurance to public and
patience related to the safe and secure practices (Cunningham, Taylor and Murphy, 2020).It has
been identified that public is concerned about reporting, recordkeeping and sharing information,
as data is the most important aspect that are required to be effectively managed as it help in
improving treatment and diagnosis and also evaluate organisation health policy effectiveness. In
addition to this has been identified that these data can further use as secondary source that
provide patients with an opportunity to get improved care served (Luccarelliand et. al., 2020).
Public confidence is necessary to be maintained by healthcare organisation as negligence or
breaches of confidentiality and security of public may lead healthcare organisation to face heavy
penalties. It has been evaluated that Woodland Nursing Home (WNH) raised a concern about a
lack of technologies for producing accurate, concise and legible reporting and record-keeping
(e.g. typical types of records completed in care practice: Care Plan, Timesheets and Rotas,
Minutes of Meetings, Recording nutritional status, Recording progress or change) at a nursing
home. In order to protect records and data of patient there are many governing laws and
legislation being imposed that are required to be adhere by organisations including Woodland
Nursing Home (WNH). As negligence of this may lead this organisation to face many
consequences that may further affect their sustainability. Public concerned related to
recordkeeping, reporting and sharing information is real. It is essential for healthcare
organisation to build confidence for effective practices and conduct ethical business operations.
Furthermore, it has been underlined that it is essential for organisations like Woodland Nursing
Home (WNH) to strongly maintain reliability and trustworthiness of care that they provide to
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patience in order to enhance their services effectiveness. Any negligence to maintain and record
information of patient may not only affect their confidentiality but also affects services which are
being provided by healthcare organisations (Managa, 2020). It is essential to effectively promote
and maintain public conference in the medical profession. There are number of concerns of
public associated with the proper maintenance of sharing information reporting and record
keeping which is real and are required to be effectively consider by health care organisations like
Woodland Nursing Home (WNH) in order to provide safe and secure health treatments or
facilities.It has been identified that public is concerned that if healthcare organisations is
involved in any criminal offence and share their information to unauthorised external internal
individual then they may have to face many consequence. Along with this it has been identified
that public is also concerned that it if medical professional make serious clinical errors then
patients can raise complaint about a medical professional with the help of proper recording and
reporting (Wilson, and et. al., 2020). Furthermore, it is essential for regulatory bodies like
Woodland Nursing Home (WNH) and other Healthcare organisations to have a proper
understanding of the compliances that are required to be followed by them. Furthermore it has
been evaluated that data of patients plays most important for them as it includes personal
information, thus their concerns related to negligence of reporting, recording and sharing
information to unauthorised individuals is real, as it is essential for healthcare organisations to
not only improve the treatment and services but also provide make the aware about the
information to patients in order to make them assure that they getting safe and effective care in
all the aspects.
Data recording is one of the most important and vital aspect especially in a health and
service care sector (Harding, Bekaert and Appleton, 2020). It is essential for health practitioner
and other professionals to engage in the crucial investigation of the incident and maintain oral as
well as written record of the information’s. A good medical report not only provides a number of
benefits for the organisation but also act as an essential component to provide safe and effective
health care services to individual. It has been identified that public concerned about reporting
and recording is real as they have a legal records or good medical records in order to defend a
complaint in case any clinical negligence. In addition to this it also provide up-to-date
information and accurate medical treatment process to patient individual data. Furthermore, it
has been identified that recorded, handwritten or data plays an essential role for continuity of
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care for patients. It not only helps in maintaining best practices but also facilitate proper
communication between Healthcare professionals and public. Thus, it is important for Healthcare
organisation to maintain proper data record in order to provide adequate satisfaction to public, as
with the help of this they can file complaint or claim against the negligence of services.
Promotion of Access to Information Act (PAIA), No 2 of 2000 states that individuals have
access to Information under this act as it essential for patients to have right to access their own
medical records. It will help them for future treatment purpose in a well defined and effective
manner. In addition to this, it has been identified that public is concerned about reporting and
recording and this concern of there is real, as with the help of proper recording and repeating
they have accurate, complete and up-to-date information about their health treatment through
which they can get more efficient care. This information’s can be further allowing them to have
treatment in easy manner. In addition to this it allows individual to have safe care.. Furthermore,
it has been identified that with the help of having recording patient can have proper interaction or
communication with health care professional can have access to safer Healthcare services. The
most important reason that makes public to concern about recording and recordkeeping is that
they can provide this information as evidence in court of law if any form of negligence is being
done by Healthcare sector. In addition to this it has been underlined that with the help of this
they can ensure continuity of care in a well defined and effective manner. These records allow
patients to have improved communication with the medical professional as medical history
provide number of advantages through which clinical physicians can have more in-depth analysis
and can provide diagnosis more quickly. Furthermore this is been identified that with the help of
recording patients can assure easy follow up with doctors through which proper track on
continuing care can be assured. With the help of this patient can assure proper as well as accurate
supervision in a quick and easy manner as with the help of verifying past exams as well as
procedures patients can assure future Healthcare services in more efficient and easy manner. In
addition to this it has been underlined that with help of record patients can be sure quick services
emergency situation with the help of having evaluation of medical history. Thus, it has been
identified that the concern of public related to reporting and recordkeeping and sharing
information is real as it allows them to have more quick and accessible future Healthcare
services.
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In addition to this, it has been evaluated that that Woodland Nursing Home (WNH) has been
experiencing, such as a lack of new and modern technologies to reporting and record-keeping, a
lack of process of producing accurate, legible, concise and coherent records regarding service
user’s care and support and inadequate process of compliance with national and local policies
and guidelines. Thus, it is essential to improve the process of producing accurate, legible, concise
and coherent records regarding the service user’s support and care. Thus, in order to effectively
overcome the concern of public in terms of reporting, recordkeeping and sharing information it is
important for healthcare organisations like Woodland Nursing Home (WNH) professional to
effectively engage in ethical for accurate data recording practices. With the help of proper record
treatment as well as care will be provided to individuals use technologies in reporting and
recording. In this with the assistance of electronic data and information storing measures provide
assistance in keeping and maintaining records in Woodland Nursing Home (WNH). Proper
maintenance of data enhance further treatment effectiveness and also satisfy concerned of public
in an effective manner, as with the help of this public can receive treatment elsewhere in the
Woodland Nursing Home (WNH). In addition to this, it also helps in enhancing loyalty of public
towards health organisation. It is also important for healthcare organisation to effectively engage
in investigating with the help of proper audit as it enhances trust and loyalty of public towards
organisation (Rembert, 2020). Thus, it has been identified that it is essential for Healthcare
organisation to properly listen and investigate complaints and concerned of individual operations
in order to provide them a higher standard services. It has been identified that leading
organisations like Woodland Nursing Home (WNH) is also required to properly train
professional within workplace structure to engage in medical treatments services, as it will
significantly allows them to overcome the concern of public or individuals. With the help of
these practices concern of public can be overcome in an effective manner. It is also essential for
Woodland Nursing Home (WNH) to conduct proper audit of accounts services and other aspects
and prepare statistics on the performance. Organisation is also required to engage in the practices
of investigating complaints, legal claim and other incidents in order to enhance their
transparency. Furthermore, concern of public related to recordkeeping, sharing information can
be overcome with the help of implementing strict security measures in order to make sure that
individual patient data and information cannot be identified by any other party which is not
associated. Along with this, Woodland Nursing Home (WNH) is required to track patient details
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