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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in order to make sure that the information is confidential and does not share with any other
individual for own benefit. By providing genuine and transparent care this concern of public can
be effectively overcome.
Thus, according to the above mentioned analysis it has been identified that public is having
real concerned towards reporting, recording and sharing information of their data which is
required to be effectively managed and record . Negligence of this may lead organisations like
Woodland Nursing Home (WNH) to face many consequences and challenges. Thus, it is
essential for Woodland Nursing Home (WNH) to confidentially practice recordkeeping,
reporting and sharing information practices in order to effectively manage patient data. It has
been identified that in Woodland Nursing Home (WNH) every individual must have legal duty
to keep information about patients in confidential manner also comply with the health care
standards in order to manage data of patient in an effective manner and does not disclose them to
third parties without the concern of individual. However in terms with emergency services there
are number of laws and legislation through which Healthcare organisations can share
information. Thus, it is essential for Woodland Nursing Home (WNH) to have proper
understanding of the standards in order to provide efficient care and overcome the concern of
public and conduct their services in effective manner. Mentioned below there are some contract
that can be used by Woodland Nursing Home (WNH) in order to take concerned of patient if
there is any situation of emergency is necessary to protect someone life:
Article 6(1)(b) is necessary for a contract where the individual has a contract with the Trust
or because the individual has asked the Trust to take specific steps before entering into a
contract.
Where the terms below used in the above mean:
 Consent: the individual has given clear consent for the Trust to process their personal
data for a specific purpose.
 Contract: the processing is necessary for a contract the individual has with the Trust, or
because they have asked the Trust to take specific steps before entering into a contract.
 Legal obligation: the processing is necessary for the Trust to comply with the law (not
including contractual obligations).
 Vital interests: the processing is necessary to protect someone’s life.
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 Public task: the processing is necessary for the Trust to perform a task in the public
interest or for the Trusts official functions, and the task or function has a clear basis in
law.
Recommendations
It is recommended that it is very necessary for the healthcare professionals to follow data
protection act and general data protection regulations at the time of sharing information. Apart
from this, considering wellbeing and safety of people is very necessary while sharing the
information. Decision regarding the sharing of information must be based on the wellbeing and
safety of people as well as the actions that may affect the other people. In addition to this,
keeping the record of decisions is also very necessary. So, Health Care professionals must keep
records about the patient regarding what information have shared for what purpose and from
whom.
Conclusion
As per the above discussion, it has been concluded that it is very important for the health
care organisations to compliance with the statutory requirements. The care organisations need to
work within the regulatory and legal requirements. The data protection act, 1998 is an important
regulatory law which aims to protect information of patient. Storing the records is an integral
part of professional practices within the health care organisation. For enabling good record
keeping, it is necessary to follow the appropriate process.
TASK 2
Describe how technology is used in recording and reporting in own care setting
Technology is playing most important role in supporting high quality care. With the help
of technology data can be captured, stored and compare with more efficiency. It is essential to
maintain safety, dignity and concern of individuals while maintaining confidentiality of data. In
this computer system for patient records significantly enhance effectiveness in providing
affordable and improve recording and reporting. Healthcare organisation like Woodland Nursing
Home (WNH) can effectively record data and can further provide access to the committee with
the list of clinical logic current problems and status of patient and most recent information
related to different treatment option for patient condition. With the help of technology easy
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access to data can be provided in addition to this existing identify the Computer Based patient
record is mainly defined (Kilgore, 2020).
In addition to this electronic patient record which is defined as a system and specifically
designed to provide support to users by providing them accessibility to record accurately, data
clinical decision support system, alert, reminder and other medical knowledge. With the help of
technology legal audits can be done in more effective manner that enhances quality assurance.
Technology is effectively used in the hospital information system through which clinical as well
as administrative function on medical information system is doing effectively manner in which
individual data or information gets stored and processed in computer. Furthermore it have been
underlined that computer-based patient record is providing significant positive impact upon
quality patient care from different ways it not only improve the quality to patient care data but
also allow to integrate information in time effective manner. With the help of technological data
record practitioners can have medical knowledge whenever there is a need in easy and time
effective manner (Holmgren, Botelho, and Brandt, 2020). Furthermore one of the most important
advantages of technology in reporting and recording in is that it provides cost-effective system
through which elimination of unnecessary information also assured. With the help of this
communication among providers and patients via online portals, email and text messages also
undertaken with more efficiency.
Explain the benefits of involving service users in record keeping processes
According to the analysis of many evidences it has been identified that by supporting
patients to actively involved in their own care not only provide efficient support in treatment but
also lead towards improving outcomes as well as experience. In allows patients to manage their
own condition that will effectively enhance health care services. It has been identified that every
individual have their own needs, believes values and choices. One-size-fits-all does not work in
context with health care support and care. It is essential to involve service users in recordkeeping
processes as it will not only enhance transparency but also provide the maximum level of
satisfaction and trust towards healthcare. It has been identified that there are number of concern
of public in context with recording reporting and sharing information thus by involving them in
recordkeeping process not only allow to overcome that concern but also provide centred care
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treatment as well as support in more effective manner (Scholl, Pomeshchikov, and Rodríguez
Bolívar, 2020).
In addition to this has been underlined that by involving service users in record keeping
process also develop good communication among healthcare practitioners and public that
enhance efficiency of healthcare support in many ways. Thus according to above analysis it has
been identified that by involving a public in record keeping effectively enhance effectiveness of
treatment and also maximise loyalty, satisfaction and experience. Along with is it also enhances
transparency of healthcare organisation and will further lead towards creating good mind set
amongst service users. It will also help in overcoming their fear related to maintaining, recording
and sharing of information in a well define and effective manner (Armstrong, 2020). Thus, with
the help of these benefits by involving service user in record-keeping purposes efficiency of
healthcare services can be enhanced with more effectiveness.
Review the use of digital technology in relation to own medical management procedures or care
plan
According to the analysis of Woodland Nursing Home (WNH) medical management
procedure it has been identified that there is a concern related to lack of technology for
producing accurate and reliable reporting as well as recording. Furthermore according to the
analysis it has been identified that in Woodland Nursing Home (WNH) there are a number of
problems or challenges that has been experiences by this organisation. In addition to this, it has
been evaluated that modern or new technology helps to record and report data and information of
patients (Mallawarachchi and Mallawarachchi, 2020).
Lack of technology is a major challenge which is creating number of issues in terms of
précising information or data of patient in a well-defined and effective manner. Thus in order to
make improvement in this it is essential to undertake use of different technologies, computer
based recording and other technological measures in order to maintain and keep data. With the
help of this Woodland Nursing Home (WNH) can not only improve the process of storing data
but can easily comply with National and local policy as well as guidance in more effective
manner. According to the analyses that has been identified that with the use of digital technology
in medical care in Woodland Nursing Home (WNH) Healthcare authorities within respective
care unit can overcome problems in order to maintain data and more effective manner.
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Evaluate the effectiveness of the use of technology in terms of meeting service user needs,
ensuring appropriate care is given and maintaining confidentiality
Technology is effectively enhancing effectiveness of healthcare services and cares and is
providing care to patients in a well-defined an effective manner. However in context with
meeting service user needs and providing them appropriate care while maintaining
confidentiality effectiveness technology is playing most important role. As with the use of
technology improvement in quality healthcare efficiency safety and cost is being managed in an
effective manner. It is transforming the manner of healthcare services that has been providing to
customers.
As per the analysis it has been identified that with the use of technology Health Care
practitioner or nurses can prevent errors as well as adverse events like miscommunication,
medication errors, delay in treatment and other more is important aspects in an effective manner.
There are different type of technological devices that can be caused by medical care practitioners
in order to provide care to patient while reducing medication errors. While in context with
maintaining confidentiality, with the use of different computerized electric systems as well as
data storing system information and data of patients can be stored in more effective manner
(Karnadipa, and Nurfikri, 2020). Technology is providing efficient support to health care
organisations that enhance experience and satisfaction level of patient towards health facilities
and treatment in effective manner. With the help of different type of data recording system
information can be captured with more efficiency and can further access in real time it further
effectively support in for the decision-making as well as treatment and provide medical
practitioners an easy way to provide effective care to patient (Warren, 2020). Thus according to
the above mentioned analysis it has been identified that technology is significantly enhancing
effectiveness of providing or meeting service user needs. It not only providing confidentiality but
also enhances their experience towards health care services in an effective manner. With the help
of technology patience and health care units can gain number of benefits.
Produce accurate, legible, concise and coherent records regarding service user care for different
service users following own setting’s guidelines
It is essential to provide reliable, accurate and consistent record related to service user for
different servers users in which it is essential to provide accurate and concise, up-to-date, reliable
17

and easy to read in plain language that can be understood by service user. In addition to this it is
also essential to provide documentary evidence of authorities which is involved with individual
service user along with the information when dealing with complaints or investigation (Rembert,
2020). It is also important that every service user is provided with accurate and distinguish
between opinions, assessment, facts, judgement and decision. It has been identified that it is also
essential to provide information in clear and chronological manner. With the help of service user
involvement in Woodland Nursing Home (WNH) it is essential to conduct practices of service
user involvement in order to identify their comment related to agree or disagree with professional
opinion as well as recording. In addition, with this it is also essential to emphasize upon data
Protection Act 1998 and email of fax information about service user when it is important
(Cunningham, Taylor, and Murphy, 2020). Confidentiality is also one of the most important
factors which is likely to be other while assuring consent of patience.
Care plan is significant aspect of providing high standard quality care to the patients. It not
only helps in supporting the care provider’s roles in administering consistent care but also make
the care providers able to customise the types and levels of support for each individual on the
basis of their individual needs. Apart from this, risk assessment is important as it assist in
forming crucial part of occupational health and safety management plan. It helps in developing
awareness of risks and hazards as well as also assist in determining who might be at risk.
Incident reporting is defined as a tool which make the health care professionals able to disclose
adverse events known as unintended injury which is caused through healthcare management
instead of disease of patient and near misses. Incident reporting is important as it increases the
awareness of organisation regarding the things which can go wrong so that preventing and
corrective actions can be taken immediately. In healthcare, nutrition is very important as the
healthy diet promotes healthy outcomes, development and aging, supports normal growth and
assist in maintaining healthy body weight. Apart from this, it helps in declining the risk of
diseases which lead to overall health and wellbeing of individuals throughout the life.
Explain different aspects of own management of service user records with reference to
compliance with national and local policies and guidelines
It is essential to manage records and report in compliance with National and local policy as
well as guidelines. It is important for organisations engaged in healthcare sector to frame their
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processes and policies and day-to-day operations while complying with regulations and laws in a
well-defined and effective manner (MALLAWARACHCHİ, and MALLAWARACHCHI,
2020). It helps in providing decision making in more effective manner. Further it has been
underlined that it is important for organisation those who are conducting their operations in
healthcare sector to have proper corporate compliance program in order to overcome the corrupt
policies and practices in order to enhance transparency but also demonstrate a good compliance
system with an organisation.
It is essential to design awareness of essential local as well as national guidelines within
Woodland Nursing Home (WNH) structure and among all the healthcare practitioners and nurse
in order to conduct services in an effective manner. By complying with local and national
policies as well as guidelines Woodland Nursing Home (WNH) can effectively provide
satisfactory healthcare services to patient in a well-defined and effective manner. Furthermore,
has been evaluated that there are different type of legislation of service user record is being
formulated by United Kingdom local and national government authorities that are required to be
adhered byWoodland Nursing Home (WNH) in order to conduct effective health care (Harding,
Bekaert, and Appleton, 2020).
Analyse the process of maintaining records in own setting, identifying any potential or actual
difficulties
According to the analysis of above case scenario it has been identified that Woodland
Nursing Home (WNH) facing the issue of managing data in an effective manner. Along with this
it has been identified that there is a lack of modern and new technology is being reported. Further
it has been identified that lack of process of process during accurate, coherent and concise data
and inadequate process of compliance with national and local policies and guidelines is also
measured in respective organisation (Wilson et al., 2020). This is enhancing difficulty level and
lead Woodland Nursing Home (WNH) towards providing inefficient services to patients. Thus in
this it is essential for Woodland Nursing Home (WNH) to maintain record while identifying
actual difficulties in an effective manner with the help of proper plant technology and adhering
to the all government authorities. Proper maintenance of records can be assured that it will
significantly enhance transparency and further aid organisation to provide high quality services
to patients.
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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
According to the analysis it has been identified that while complete documentation in terms
of meeting service user needs and ensuring appropriate care provide effectiveness in services can
be enhanced. In addition to this it has been identified that there are different technologies and
legal obligations as well as laws essential while recording and reporting. With the Healthcare
organisation can effectively enhance their service effectiveness and efficiency. In order to
conduct effective reporting it is essential to Woodland Nursing Home (WNH) to abide all the
legislations and undertake use of new technology in order to effectively fulfil service user needs
(Kelley, and Gilad, 2020). It will significantly enhance long-term sustainability in a well-defined
and effective manner.
CONCLUSION
As per the above-mentioned report it has been concluded that proper recording, reporting
and management of data is one of the most important aspect in organisation which enhance
transparency of healthcare organisation. In addition to this has been identified that by
maintaining data and information of patients organisation can enhance transparency and can
further conduct services in a well-defined and effective manner. It is essential for Healthcare
organisation to abide all the legislations and laws that are staying in force by government
authorities. It will significantly enhance long term sustainability and practices.
20

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