Unit 17 Report: Effective Reporting and Record-keeping in Healthcare

This report, focusing on Unit 17, delves into the crucial aspects of effective reporting and record-keeping within health and social care services. It begins by outlining statutory requirements, including the Data Protection Act, Access to Health Records Act, and Medical Reports Act, emphasizing the importance of accurate and timely clinical records. The report then describes the roles of regulatory and inspecting bodies like the Care Quality Commission (CQC) and the requirements of RIDDOR. It analyzes the implications of non-compliance, including financial penalties, industry disqualification, and reputational damage. The report further details the processes of storing and sharing records, both internally and externally, and evaluates the current practices within a care setting, offering recommendations for improvement. The report underscores the significance of maintaining confidentiality, ensuring patient safety, and adhering to legal and ethical guidelines in healthcare documentation.

Unit 17: Effective Reporting and Record-keeping in Health and Social Care Services
Sophie Keems
S0246059
Word count: 3500
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Table of Contents
Introduction.................................................................................................3
P1 Describe the statutory requirements for reporting and record-keeping
in own care setting......................................................................................3
P2 Describe the regulatory and inspecting bodies’ requirements for
reporting and record-keeping in a care setting...........................................5
M1 Analyse the implications of non-compliance with legislation, regulating
and inspecting bodies’ requirements..........................................................7
D1 Evaluate the consequences of non-compliance concerning the media,
service user safety and the credibility of the care setting..........................8
P3 Describe the process of storing of records in their own care setting.....9
P4 Explain the reasons for sharing information within its own setting and
with external bodies..................................................................................10
P5 Accurately illustrates the internal and external requirements for
recording information in own care setting................................................11
M2 Examine the current processes in own care setting related to storing
and sharing records..................................................................................11
D2 Evaluate own work setting’s arrangements and processes for storing
and sharing information, making recommendations for improvement.....12
Conclusion.................................................................................................13
References................................................................................................14
Introduction
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The health care processes a large amount of data, and so this information
must be recorded and kept safe for reference. Effective reporting and
record-keeping in health and social Care empower patients by putting
them in control of their experience of their health. Record keeping in
health also delivers integrated patient care breaking down geographical,
professional, and institutional boundaries. Effective reporting and
Recordkeeping are an essential activity to care service because it
prevents patients from repeating the same information to many
professionals which are found to be one of the greatest frustrations for
service users. Over the years, effective reporting and record-keeping have
ensured and improved patient safety by preventing gaps and mistakes in
patient’s history record in terms of treatment. Record keeping in health
and social care has caused a positive impact in treatment by enabling
self-management care for patients that are recovering from an acute
condition. Patients share their health information with their clinicians
whenever they visit the health centre throughout their lives, therefore
recording this information and using it to improve people’s health is useful
to medicine. These recorded data from various health care institution and
geographic locations present a significant advantage in innovative,
efficient, and cost-effective research thus informs decisions in clinical
medicine, health service planning and public health. Governments and
other health agencies have legalised and prioritised the use of routinely
recording health data as tools to improve patients care, transform health
research, and improve health care efficiency (Coster C et al.,2006). This
report illustrates legal and regulatory aspects in record keeping in health
care, it further explains how technology has brought positive impact in
record keeping. This report also demonstrates how record can be kept and
maintain national and local policies.
P1 Describe the statutory requirements for reporting and record-
keeping in own care setting
There are three legislation governing access to patient health record: The
Data Protection Act 1998. The access to health records Act 1990, and the
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Medical reports Act 1998. The first governs the right of living individuals
and authorised persons, the second governs access to deceased patients’
records, and the third governs the right for individuals to access reports
relating to themselves provided by medical practitioners for employment
or insurance purposes. Access to this legislation is limited to protects
patients’ records. Also, records can be limited to patients if it could cause
harm to the patients mental or physical health. Parents have the right to
access their children health records, but their confidentiality must be
checked as well. (Dubovitskaya, Xu, Ryu, Schumacher, & Wang, 2017).
Providing an accurate, timely, relevant clinical record that ensures the
safety and coordinates care that involves the patient, carer and family are
especially important in health care. Clinical and administrative staff
contributing to a patient must provide an accurate health record which
can be used to determine clinical decision making, improve patient care
through clear communication of the assessment and treatment and care
planning rational. There are several statutory requirements in reporting
and record-keeping in my own specialist area in my own health and care
setting. All information recorded must be up to date with every
information their patient may share with them. This information must be
kept safe and must be easy to access them for future use. (Archenaa &
Anita, 2015). Health practitioners are accountable for ensuring that they
are capable and aware of and knows how to use an information system,
for example, using an electronic patient record system and medical
devices in accordance. Written data must be readable, legible, and written
in black ink to enable photocopying or scanning of documents; signed and
be kept safe in a file if required.
The records must be maintained and kept in a way that it can be
transferred to other clinicians’ institutions in case of emergencies. There
are situations whereby patients may lack their mental capacity to answer
their own medical records and are not capable of making decisions at that
moment. It is therefore essential to record any risks identified or problems
that may have risen and that taken to rectify them if another episode
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occurs in the future. Care records have been introduced to enable sharing
of essential information about a patient, such as medication, allergies, and
adverse reactions. However, any required information of a patient must
abide by the law by following the Data Protection Act 1998. (Wager, Lee,
& Glaser, 2017). Every legal requirement and local policies concerning the
confidentiality of health records must always be governed. Health records
taken in a form media must be kept securely in lockable trolleys to avoid
leaked information. Also, records must be continuously updated; this is
important in terms of treatment. All recorded information must be timed,
dated, and always signed. (Walton III, 2016).
P2 Describe the regulatory and inspecting bodies’ requirements
for reporting and record-keeping in a care setting
Care Quality Commission (CQC): The purpose of CQC is to monitor, inspect
and regulate all health and social care services. CQC commission ensures
that the quality and safety of care in hospitals, dentist, and care homes.
CQC is set to protect and promote the health and safety of the people
under health and social care services under HSCA 2008; this includes the
NHS and local authorities as well as independent sectors in health and
social care. In health, several rules have been outlines by CQC which are
required to abide. CQC check that health sectors are complying with the
regulations in terms of record keeping. CQC requires health sectors to
maintain records about their employees, records of patients, records of
incidents such as accidents or a fight etc.; most importantly they check
that health and social care legislations Acts guidelines have been followed
(Care Quality Commission, 2019). Checking and inspecting medical
records in hospitals and care homes helps CQC to assess the quality of
care being provided to the patients and workers.
Reporting injuries, diseases and dangerous, occurrences in health and
social care (RIDDOR): RIDDOR is used by employers, self-employed and
anyone in control of a business required and demanded to report any
incidents occurred at the workplace. There are seven types of categories
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of RIDDOR, these are injuries, deaths, work-related disease, dangerous
occurrence, and gas incidents. Any death that occurred at work or related
to work must be recorded. Specified injuries that need to be recorded
include bone fracture, arm amputation, loss of sight or reduction of
eyesight, skin burns, head injuries leading to asphyxia. Reportable
diseases at work include dermatitis, severe cramps of legs and arms,
hand-arm vibration syndrome, occupational cancer due to radiation and
any illnesses attributed to the exposure of biological agent at
work. Reporting incidents at work helps authorities to be aware of events,
and this helps them to investigate it further if the situation is serious. It is
an offence not to report injuries and dangerous occurrences disease.
(Department of Health, 2009). RIDDOR though does lead employees to
health and safety, there are other regulatory and enforcing authorities in
the health and social care system that goes deeper into health
investigations. These include the Care Quality Commission (CQC), the
Midwifery Council (NMC) and the General Medical Council (GMC). These
governing bodies apply specific legislation which must be abiding by any
registered health care centre.
Information Commissioner Officer: Information Commissioner Officer
educates on how information should be recorded and kept safe. They
demand data mapping because they believe that this helps clarify what
personal data the organisation holds and where. Documented information
must reflect on the current situation, this means that regular reviews on
the information processed must be regulated to ensure that
documentation remains accurate and up to date. Information should not
be move regularly but instead kept isolated so that the staffs would be
precise to know where each document is.
Public and local authorities: Public and local authority in health and safety
enforcement is done through environmental health officers who are
responsible for food safety, housing, and environmental nuisance. They
are responsible for regulating and inspecting sectors such as retail,
wholesale distribution and warehousing, hotel and catering premises and
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offices. Any occurrence incidents must be reported to local police and
security agencies for further investigations.
Schools: Schools are one of the most important institutions; therefore,
record-keeping is highly required. Good health and safety records,
keeping ensure information easily retrieved and be passed on from one
person to another, ensuring consistency. It also provides that the
company can demonstrate reasonable compliance with legal duties under
health and safety law.
It is a legal requirement to keep records of academic performances,
attendance and health and safety documents for inspection. Health and
Safety Executive Inspectors and Union Health and Safety Representatives
have a legal right to inspect health and safety records. Incidents such as
fire evacuations, accidents, death must be recorded in risk assessment,
and a copy should be sent to health and safety services for further
investigation. Health and Safety inspectors expect assessment files such
as COSHH assessment, RIDDOR, fire risk assessment and general risk
assessment to be available always.
M1 Analyse the implications of non-compliance with legislation,
regulating and inspecting bodies’ requirements
Non-compliance in health and safety legislation and company regulations
results in an undesirable effect on a workplace, leading to loss of life,
income reduction and can cause one to be disabled. Therefore,
Compliance with and monitoring of the health and safety programme are
consequently of the most considerable importance for a business to
reduce these work-related risks. In our series on occupational health and
safety in the workplace. Enforcement is one of the core components of the
operating model that the Care Quality Commission uses to achieve its
purpose and perform its role. Non-compliance is when an organisation
fails to abide by the rules and legislation set out by authorities. Breaching
health and safety rules and regulations is a criminal offence. Companies
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and organisations are subject to ensure the safety of the environment for
everyone, refusing to do so results in fines and prison sentences.
Financial penalties: A certain amount of money can be collected from the
company that breaches any health legislation. According to Barret (2009),
a fine is one of the most common consequences to be faced when QCQ
finds the company guilty of non-compliance. If an employee is injured at a
workplace where the rules were not fully practised or implanted, there
would be a claim against the business. CQC has issued a fixed penalty
notice to Prime Life Limited following their failure to comply with
Regulation 20A of the Health and Social Care Act (2008) (Regulated
Activities). The most severe consequences of being faced are when a
potential injury or death occurs in the workplace. For example, Sir Robert
McAlpine was fined an amount of £200,000 after the death of a worker
due to health and safety negligence. In some situations, the highest
amount that was charged with a company due to negligence was
£800,000, and this is said to rise over the years.
Industry disqualification and reputation damage: The business reputation
can be ruined when QCQ classify it as unfit. Disqualification can be
applied, which can cause the status of the company to be destroyed. For
example, East Kent Hospital Trust has been warned by inspectors to make
some improvement. The hospital was required to improve on safety,
effectiveness, responsiveness, and leadership. The damage caused to an
organisation’s reputation by a criminal conviction can last longer,
resulting in financial breakdown and loss of investors.
Imprisonment: Breaching health and safety law can lead to imprisonment
for up to six months. Individuals that may not end up in prison may still
have criminal records which could restrict them from working. This can
lead to the organisation properties ceased until errors have been rectified.
The loss of production will result in loss of income which can cause the
company to collapse. Loss of current or potential staff would occur due to
the reputation of the company. Nobody would want to work for a company
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that has been prosecuted and found guilty for beaching health and safety
legislation law and regulation. Therefore, an organisation needs to comply
with all the legislation to avoid the consequences.
D1 Evaluate the consequences of non-compliance concerning the
media, service user safety and the credibility of the care setting
The social media refers to internet-based tools that allow individuals to
communicate and share information with one another on ideas. The social
media sites provide different kinds of features that enable different
purposes, this includes blogs, social networks, video, and photo-sharing.
Several social media tools are available to promote health and social care.
These tools can be used to enhance professional networking and
education as well as improving patient care and public health
organisations. However, social media also present some disadvantages
and a potential risk to health and social care professionals due to the
distribution of inadequate -quality information, leaking patient private
information and violating personal boundaries. Patients health information
are inherently private and confidential, it would be very distressing for any
of their information relating to their personal health to be leaked or
mishandled on social media.
There are ways whereby data can be breached in the health Sector. This
includes data posted or faxed to an incorrect recipient, data hacked, and
data sent by email to a wrong recipient. Most of these non-compliance
cases occurs accidentally made during routine care. The NHS has been
minimising this problem by investing in robust IT securities and increasing
staffs. Health care services and companies that use and process personal
data are under data protection legislation such as the GDPR and Data
Protection Act 2018. This legislation demands all companies to register
with the Information Commissioner’s Office (ICO). If any information is to
be leaked online, then it means that there has been a breach of the GDPR
and Data Protection Acts 2018 law.
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Over the years, there have been some scenarios whereby patient’s
medical information made its way into the public domain without the
consent of the person. This caused the company great damage and ruined
their reputation. A tremendous amount of money was fined by the
prosecutor for their negligence and being non-compliance. There was a
case in 2015 whereby a pharmacy was fined £130,000 for selling over
20,000 patients details such as their names and contact through an online
marketing company. The pharmacy company was fined and shut down.
The reputation of the company discredited and ruined. In the year 2017,
the ICO announced that Royal Free NHS Foundation Trust failed their
compliance with the Data Protection Act when giving about 1.6 patients
information to Google DeepMind for research that tested for an acute
kidney injury. The private health company was fined £200,000 for
breaching the law. In care settings, credibility is highly important. People
tend to the internet in search of high quality and trustworthy health
centres they can trust with their health information and personal details.
Many patients share their opinion on how they trust their doctors more
than the internet, yet in many situations, the internet is the first channel
of information consulted. It is therefore important for these organisations
to be credible enough to meet the patient requirement as well as health
care regulations.
LO2 Explore the internal and external recording requirements in a
care setting
P3 Describe the process of storing of records in their own care
setting
Patients records are to be stored accurately and genuinely. There are
different ways of record-keeping used in health care. Hand-written records
are very common in some workplaces. The updated version of record-
keeping is by storing it on the computer-based system. Most facilities tend
you use both hand-written and computer to store information. Patients
visiting for the first are required to fill in their information for registration.
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This is stored on the computer for future use (Dubovitskaya et al., 2017).
One to one discussion made between the doctor and the patients are
usually recorded on the computer to protect the patient’s medical
information privacy. Doctors are required to know how to use the
information systems and tools to avoid loss or breach of information. Any
written records must not be left unattended in public places where
unauthorised people might see them. Also, electronic must always be
protected with passwords and must sign out when not in use.
P4 Explain the reasons for sharing information within its own
setting and with external bodies
Sharing information to the right people at the right time is vital in health
and safety. The Health and Social (Safety and Quality) Act 2015, which
came into effect on 1st October 2015 sets a duty for information allows
information to be shared legally with the notice of the patients. Sharing
information within its own setting and with external bodies are critically
important in terms of emergency situations. An unconscious patient is in
no position to answer questions so, therefore, the best way to deal with
the situation will be to ask for her medical information from her doctor to
save their life (Walton III, 2016). The patient may not be the right mind to
answer some medical questions such as allergies and any health problems
they may be having. Sharing information reduces pressure under an
urgent matter when treating a patient.
Sharing information previously recorded on the patient helps another to
understand the health needs of the patient and the quality of the
treatment needed to be given. Information needs to be shared by the
health facility with or without consent when it is reasonable, needful, and
proportionate (Archenaa & Anita, 2015). Thus, effective sharing of
information beforehand between entities, professionals and agencies is
critical for proper identification of risks, evaluation as well as service
provision. Researchers use patient information to support their findings
and identify patterns in diseases and how they respond to treatments.
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Researchers use patient information to develop new ways of predicting or
diagnosing illness and identify ways to improve clinical care. Independent
review committee assesses the researcher before granting them the use
of patient information. Bessette (2015) established that the charity
organisation must contribute to what should be shared so that the matter
is approached in a multifaceted manner.
P5 Accurately illustrates the internal and external requirements
for recording information in own care setting
The importance of keeping up-to-date data was addressed by the Care
Quality Commission recently when a care home was pronounced to have
inaccurate records. It is vital to do an up-to-date account of the internal
and external recording requirement in health, for example, care
homes. Record keeping is essential both for patients and care- home
employees. It is therefore vital that staffs are given the required training
in record-keeping. Families are required to check the patient records to
make sure they are correct. The next of kin should be only willing to share
the patient records with other family members and any reputable care
home. Precise and up-to-date recording of information and ensuring that
the clients have the necessary key information regarding their states and
treatments are the responsibilities of the care home and its
management. All records must be up to date recorded accurately by
keeping records securely by making them accessible. The records must be
clear, complete, and well written with excellent visibility. Records should
be easy to be moved in case the patient is being transferred to another
hospital or care home. External health care professionals must record
their interactions and interventions with patients. This helps care staff to
follow any instructions safely and effectively. Records of medicines
administered by external health care professionals must be available to all
care staff. Recorded notes by staffs must be dated and signed, including
any discussions that took place between the person receiving care. With
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care documents, all records of the resident are stored digitally. This
makes it easy to access with a few clicks, staff can access all the
important information needed. This information is stored under logical
categories making it easy to view relevant information.
M2 Examine the current processes in own care setting related to
storing and sharing records
The current operations in the care facility would be the way information is
being stored and shared electronically. Storing medical information on the
computer keeps them safer and more portable, and easy to share.
Healthcare records are increasingly storing their information electronically
which has enabled them to easily access and ready to share. In terms of
security, electronic devices play a vital role in data leakage. Authorised
users would be the only ones to sign in and get access to the data. There
are several reasons why record-keeping are stored electronically (Wager,
Lee, & Glaser, 2017).To abide legal compliance, some documents are
required to be kept for the future purpose; examples are accidents and
incidents that may have resulted in severe complications. Some
companies are used to online systems where occurrence incidents can be
recorded and reported to the authorities. Accidents records can be asked
for as evidence against prosecutions or claim for compensation.
Electronics such as the computer can store billions of data rather than
hand-written files being stored in a trolley, so, therefore, it enables space
in the office. Paper files must be maintained in a manner that is easily
retrievable, legible, and accessible. (Serrano et al., 2016) These files can
be destroyed in fire and flood, and this data could be lost forever.
Compared to computer storage, whereby information can be kept for
several years to satisfy legal compliance without data loss. Changing the
way information is stored on the computer allows for conversion and
migration to be updated, which would prevent the risk of data becoming
inaccessible and outdated in the future.
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People may have a concern about how technology can be used to access
information illegally. Many workers have smartphones with them at work,
which means it is possible to share information about their patients
without enough thought. So, there are increased risks of breaching
confidentiality. The General Data Protection Regulation (GDPR) regulates
the use of this information to protect individuals right. This information is
related to anything that can be used to identify a person such as a name,
email address, pictures, bank account details and medical information.
Legislations and regulations such as the Public Records Act 1958, the Data
Protection Act 1998 and this must be met by Record management
systems. Legislation requires an organisation to follow the rules when
storing and processing records in a specific way.
D2 Evaluate own work setting’s arrangements and processes for
storing and sharing information, making recommendations for
improvement
Improving ways of storing and sharing information will always be effective
in health and safety services. Developing new ways of storing and sharing
information with others should mean that staffs and patient would be
confident about it. One major problem being challenged in health and
safety in the privacy of the patient information. Information’s must be
held securely, and this can be ensured by making sure that health and
care staff are well trained in information governance, responding, and
handling to a data breach and having a designated leader on information
governance.
Patients personal information that can be used to identify such as names,
age, address, and email address must not be included when sharing data
among others or accessible by medical researchers unless it is essential
for the safety of the patient. Legislations and rules should be set and
govern for people that handle personal data, both clinal and non-clinical.
Another recommendation that can improve the safety of storing and
sharing information would be to comply with the law when using one’s
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personal confidential data. Authority should be available to monitor when
staff is going through a patient record, making sure that they follow all
rules and regulations. Patients personal information can be encrypted,
preventing hackers from stealing information stored online information
(Dubovitskaya et al., 2017). Few trusted staff should have access to the
encryption password.
Conclusion
Information will forever remain critical in health, so therefore having
access to this must be well regulated to protect the privacy of patients.
Technology has replaced the way information was stored and shared.
Today's era has caused electronics to replace paper-based manner when
handling information. Health care organisation are enforcing the use of
technology more when handling data. The use of electrons has been
proven to be useful and adequate in terms of checking records. It is fast
and reliable. Medical storage room of files is not highly needed since most
information is stored in a computerized system. The way information is
used, stored, and overseen is called information governance. This is the
principles and process used responsible for managing and handling
information. So, therefore, any medical information stored and shared
must be protected and be released to authorised people statutory
guidelines in the region.
References
Archenaa, J., & Anita, E. M. (2015). A survey of big data analytics in
healthcare and government. Procedia Computer Science, 50, 408-413.
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