Health and Social Care Record Keeping: A Level 4 Report

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EFFECTIVE REPORTING AND RECORD-KEEPING IN
HEALTH AND SOCIAL CARE SERVICES (L4)
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Table of Contents
Introduction...................................................................................................................... 2
Part 1................................................................................................................................3
Part 2................................................................................................................................9
Conclusion..................................................................................................................... 13
Reference list................................................................................................................. 14
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Introduction
Medical record documents are strictly prepared by health professionals so that they can
prepare perfect treatment plan against each disease. Bubbly Special Needs Nursery is
located in Bellingham Green in London and it comes under the London boroughs. This
organisation provides support to the autism children and they have specialist nursery to
cater all needs of individual children. Number of staffs are 4 and total places for special
children is 25. It prepares Individual Education plan so that they can meet all-important
needs of special children (Bubblyspecialneedsnursery.co.uk, 2019).
In this study, statuary requirement, record-keeping strategy will be discussed. Current
procedure of the enterprise while recording their medical data will be included.
Importance of technology while recording the data and its benefits will be considered.
Importance of local political parties’ guideline will be added so that the organisation can
execute their treatment plan systematically.
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Part 1 (LO1& LO2)
LO1
P1 Describe the statutory requirements for reporting and record keeping in own
care setting
Requirements for keeping records of healthcare provision are demonstrated in
Regulation 20 of Health and Social Care Act 2008 (App.croneri.co.uk, 2019). This
regulation explains needs of record keeping and ways through which healthcare
organisations can keep record. Bubbly Special Needs Nursery must take relevant
documentation and accurate records about autism children. It must keep records of
people employed there to offer healthcare service. Record keeping requirements are
developed based on some compliance framework. Primary requirement involves care
records that must include care services given to each autism child. Service users should
keep records of plans and medications used for treating children. Records must be
updated regularly so that healthcare authorities can get relevant information about
childcare and personnel responsible for their treatment. Records include patients’
confidentiality and dignity for which records should not be judgmental, libellous or
abusive (App.croneri.co.uk, 2019). These must be linked past and present medical
conditions of children, which shall enable external agencies and professionals to collect
desired information on children undergoing treatment in the nursery.
Caldicott report provides some principles concerning health and social care regarding
application of client information. It has six principles that shall allow the nursery to use
and record information referring children properly (Tameside.gov.uk, 2019). The first
principle is justifying purpose of information transfer and this must be defined and
scrutinised. The next principle demonstrates that the nursery cannot use information if it
is not necessary. Using minimum identifiable information is another part of this report
and this ensures individual items must be justified. The nursery requires complying all
legal requirements and using information lawfully while keeping records.
P2 Describe the regulatory and inspecting bodies’ requirements for reporting and
record keeping in a care setting
Healthcare inspecting and regulatory bodies of the UK have some specific requirements
for record keeping and reporting information. The nursery needs to follow these
requirements to ensure quality care for children. Regulatory bodies demonstrate two
reasons while encouraging healthcare organisations to keep record and report
accurately (DesRoches et al., 2012). They want compiling a complete documentation of
patients’ journey and enabling continuation of care systems for patients within and after
completion of services. Healthcare regulatory bodies want the nursery to demonstrate
care needs to be honest, clear, accurate and timely. Information must be recorded at
the time of occurrence of events. Different forms of record keeping include computer-
based systems, hand-written records or combination of both. The nursery requires
complying with all requirements concerning all forms of record keeping.
Healthcare professionals must know how to apply information tools and systems in the
nursery. They must not share any delicate information including passwords and
personal data without any prior permission of authorities (DesRoches et al., 2012).
Written records must not be kept in public places and electronic data must be protected
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with strong passwords before sign out. Additionally, healthcare professionals should not
interpret records to be prejudiced, racist or insulting.
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M1 Implications of non-compliance with legislation, regulating and inspecting
bodies’ requirements
Regulation 20 of Social care Act 2008 provides federal guidelines so that health
organization can easily implement right lawsuits in their treatment strategy. Guidelines
from government agencies guide the organization to manage their business strategy
under the perfect lawsuits and it helps the health sector to manage their legal status
effectively. Additionally, this legislation provides safe working environment and it guides
the enterprise to improve their employee retention rate (Liu, 2016).
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LO2
Introduction
In this part, present record of the Bubbly Special Needs nursery care will be discussed.
Importance of NHS, CQC will be highlighted. Procedure to improve performance level of
team work will be included in this part.
P3 Describe the process of storing of records in own care setting
Professional provider agreement is followed by Bubbly special Needs nursery so that it
can store all-important data of children in a secure manner. The care provider follows
CDS documentary storage procedure where only trained professionals store the data.
This storage strategy decrease handling issues and it creates a positive impact on their
treatment. As asserted by Liu (2016), care providers share their data with external
bodies so that government, different public organisations can understand the root cause
of the disease and change their policies to tackle it. In case of Bubbly special Needs
nursery, it has been observed that care providers select all-important valuable
resources about the children and sent it to their parents and guardian. This guides them
to take necessary steps against autism of their children. Provider manuals are followed
by the organisation so that both external and internal reviews can access the provider
record effectively. Medical records of autism children are stored both in software and in
manual medical record documentation so that they can increase their communication
with all external stakeholders. The medical practitioners use advance directive
communication strategy so that they can perform continuous interaction with all their
internal and external stakeholders within short time period (Aguilar-Escobar and
Garrido-Vega, 2016).
P4 Explain the reasons for sharing information within their own setting and with
external bodies
 For maintaining organisational reputation
 Providing accurate therapy to the users
 Bringing improvement in the service quality
Various data, such as patients’ recovery related data, provided care related data need
to be shared with the support providers in order to examine the performance of the
workers (Wager et al., 2017). The data should be recorded according to the name of the
support providers so that their skills can be analysed by noticing the recovery date of
users. Therefore, it ensures that users are able to receive proper service from the
healthcare setting. For instance, in time of providing service to the autistic child of
Bubbly Nursery, flow of the treatment needs to be maintained such as behavioural
therapy, physical therapy, and speech therapy. The support providers should update it
in the record keeping database. It helps the user to receive proper treatment even the
absence of his/her personal care provider. These are the importance of sharing data or
record in a health care venture.
External bodies such as NHS (National Health Service), CQC have the responsibility to
analyse the service status or service quality of healthcare setting. They measure the
service quality of health care sector and provide rating to the ventures. The approval of
NHS or CQC helps to increase the organisational position in the market. In case of
Bubbly Nursery, they make an effective plan before providing service to the users.
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Therefore, when experts of CQC or NHS visit the place, they are able to notice it. It has
helped the healthcare setting to earn reputation in market. It is evident from the rating of
the venture in market which is around 4.1 (bubblyspecialneedsnursery.co.uk, 2019). For
this rating, parents of autistic child are able to trust services of this healthcare for their
children.
P5 Accurately illustrate the internal and external requirements for recording
information in own care setting
Internal requirements
 Bringing improvement in the teamwork
 Developing service quality
 Analysing the weaknesses and strengths of the social care
If the support providers are able to maintain a database recording the information of
users, any workers can provide support to the users. In case of Bubbly Nursery, specific
support workers are not able to provide support to the specific users. If the previous
support provider updates the record, next one can easily get the information. Thus, by
keeping records, teamwork can be developed in the social care setting.
External requirements
 Analysis about the profit rte of the venture
 Success rate of organisation is able to increase their reputation in market
(Vermeir et al., 2015)
The main external requirement in order to keep record is to maintain organisational
reputation in the market. The people know about the legislation such as Care Act 2014,
Safeguarding Act 2006 and they prefer to use the service of the ventures, which follow
it. Thus, by keeping record, Bubbly Nursery can share success rate with their
customers. It is the strategy for increasing their profit from the contemporary market.
Therefore, it can be stated that organisations should maintain their records for earning
positive result in the society.
M2: Examine the current processes in own care setting related to storing and
sharing records
The records of own care setting has to be in accordance with the procedures of the
HSC organisations. According to Kohli, and Tan (2016), it is extremely beneficial for the
healthcare management to ensure that the records of the treatments and the
admissions of the care users are recorded suitably. This allows the management to
analyse the data and take suitable initiatives for managing the quality of the products as
well as services that are offered by the caregivers to the patients. The products as well
as servicers that has to be provided to the care users has a direct impact on the health
condition of the care users and therefore, it is indispensible for the care users to ensure
that they keep a suitable record. Records can be stored in hard drives in computers. In
addition to this, the CDS data storage systems allows the management of Bubbly
special needs nursery to store the data regarding the treatments of the patients This
allows healthcare organisations to ensure that the patients are provided with services
that are in accordance with the updated technological resources.
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Furthermore, the both the manual documentation as well as software drives shall be
used in order to record the necessary pieces of information regarding the development
of the children suffering from autism in Bubbly special needs nursery.
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Part 2 LO3
Review the use of technology in reporting and recording service user care in a
care setting
P6: Describe how technology is used in recording and reporting in own care
setting
In the modern generation there are several technological resources that allows the
healthcare organisations to store as well as record the data and use it for analysing their
strategies as well as quality of the products as well as services that have to be offered
to the children suffering from autism in Bubbly special needs nursery. According to Miah
et al., (2017), the cloud storage technology shall allow the HSC organisations to extend
their storage capacity further. The cloud storage technology shall allow the
management of Bubbly special needs nursery to store necessary pieces of information
in safe and reliable place that can only be accessed by a reliable source or employee
(Petrakaki et al., 2016). Apart from this, the computers of the present generation has
grater storage hard disk that shall allow the staffs of Bubbly special needs nursery to
store the information suitably and edit the updated information suitably. In addition to
this, the Internet of Things (IOT) can also be applied in healthcare in order to record the
daily developments of health status of the patients in Bubbly special needs nursery.
Since IoT has direct reliance with the devices that are used by the healthcare
professionals, it therefore, helps in recording the data of the patients and the dosage of
the medicines that has to be taken by the patients.
P7 Explain the benefits of involving service users in record keeping processes
Involving the service users in the record keeping process can be beneficial as it can
help in understanding their planning, delivery and development techniques and gaining
access to the service. Moreover, involving individual in the record keeping plan can
help in increasing the value of the service users and enhance the outcomes in the
medical process. In this context, technology also plays a major role in keeping medical
records and other reports in a healthcare system. It has been found that in Bubbly
special need nursery, the management of autism children requires to be presented
with digital care in order to gain attention from them. The digital care plans are found
to involve all the activities that need to be practiced on a daily basis. Hence, the
mentioned nursery can develop digital care plan for checking the IQ level of the autism
children. Moreover, use of digital technology in healthcare, such as technology enabled
care, mobile devices and digital media can enable the family members of the patients in
accessing the data and information. Hence, this would help in the improvement of the
quality of the healthcare services. In the mentioned nursery, healthcare professionals
can set quick and easy plan for the support providers. As mentioned by Vegesna et al.
(2017), healthcare professionals can implement software in order to create personalised
care plans which would contain all the necessary information about the patient.
Digital technology is helpful for the healthcare centre in gaining data of all the potential
patients. Moreover, it is important for establishing strong relationship as well as trust
among the support users are health practitioners. Digital working and practices are can
be used for automatic management of the health records that are important for getting
updates about the death number of the patients (Jenssen et al., 2016). In the mentioned
nursery, the health practitioners using this practice can eliminate the chances of
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incorrect dosages, missing of patient’s observation and inaccuracy in record keeping of
the patient’s data.
M3 Review the use of digital technology in relation to own medical management
procedures or care plan
The use of digital technology is largely useful for developing medical management in a
better way. In Bubbly nursery, it has been found that practitioners are not able to
manage the records of the patients. Hence, use of digital technology such as e-
prescriptions, e-recording system and IT technology for updating the management
system of the healthcare. In this context, it can be said that digital technology would
help the patient to set e-appointment beforehand that can decrease the chance of
standing in long queues for getting treatment from healthcare practitioners (Birnbaum et
al., 2015).
On the other hand, in perspectives of healthcare providers, use of digital technology can
help in managing the health records of the patients without even wasting much time.
The locality of London Borough can develop the digital system in healthcare for
managing all the activities in a better manner. In the Bubbly nursery, the patients with
autism difficulties can be managed effectively if the services are passed in a digital
manner. For example, use of cloud computing technology can help the organization to
manage the data of the autism patients in an effective way. This system can help the
healthcare professionals to increase efficiency level in healthcare services.
LO4 Demonstrate how to keep and maintain records in own care setting in line
with national and local policies
P8 Produce accurate, legible, concise and coherent records regarding service
user care for different service users following own setting’s guidelines
For maintaining and evaluating different aspects that has been closely associated with
the maintenance of effective in addition to efficient records, it is mostly essential to keep
a proper identification of diversified sources. It can be extremely helpful at identifying
the ways of resources, revenue and fund generation (Friend and Kohn, 2018).
Maintenance of effective records might also be helpful at scrutinizing and observing the
growth ratios of different organizations.
In addition to that, record are also extremely useful at preparing economical statements
that might become useful at keeping tracks of different kinds of expenses and proper
tax returns (Ford et al., 2016). Recordkeeping has also been extremely relevant towards
sorting and storing a numerous amount of data in a simple and co-relevant way.
Recordkeeping can also be tremendously helpful at searching appropriate data at the
point of need. The proper functionality of entire recordkeeping process can be
admirable at the time of any kind of special need or emergency. As an instance, through
the help of appropriate recordkeeping, the special characteristics of autistic child can be
traced in an effective manner so that the special need of that autistic child can be
mesmerized at time of need or emergency.
Recordkeeping at many different instances mainly enable some structure of storage so
that the information of different autistic child can be recorded in a concise and
structured way at user care (Czaja et al., 2015). Records are generally being served as
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the evidence of different actions in addition to decisions that take place at the time of
communication at certain extension. Moreover, records can act as a prefabricated way
of outlining and mitigating conflictions at own care settings. Records can keep out
confliction since it can radically bring on transparency in context of an entire
organization and the employees belonging from that healthcare organization.
Proper usages of technological equipments at different healthcare sectors are generally
extremely helpful at mitigating the existing communication gap between the patient’s
families with the medical stuffs (Bailey et al., 2016). Technologies can also become
extremely helpful towards reducing the overall medical errors that might badly affect an
autistic child. In addition to that, technology improves the overall safety measurements
of a range of different healthcare institute, which will ultimately be helpful at keeping up
the overall safety of autistic child.
Proper usage of technological record keeping might also be extremely helpful at
keeping the family member of autistic patients aware of the condition of these patients.
Moreover, technological record keeping might also be extremely helpful at keeping a
proper guidance regarding the diet chart and therapy seasons of autistics patients.
Different exercise schedules and proper timing of sleep can also be tracked while
applying technological recordkeeping (Ancker et al., 2015). Different parameters of
doctor advice and recommendation regarding a particular patient can also be tracked
back through the help of effective recordkeeping. Moreover, the other medical stuffs like
nurses and interns can understand and analyse the current position of a patient through
the help of technological recordkeeping as they can easily assess the proper
recommendation regarding a respective patient at certain extension.
P9 Explain different aspects of own management of service user records with
reference to compliance with national and local policies and guidelines
As per the national guidelines and policies, our management regarding service needed
to make sure the fact that individual autistic patients that has been treated by our care
hone has the prefabricated right of accessing their personal health records. As per the
local rules and guidelines, in some circumstances, individuals can also assess the
records of other individuals (Mackert et al., 2016).
As per the rules of government, we are bound towards providing autistic patients with
their previous health records within 21 days of records. In some of limited
circumstances, the family members and other relatives of autistic patients can also
request us for the records. As per the Data Protection Act 2018, we need to make sure
the fact that we always maintain and record different physical and mental condition of
our entire patient base since patients and their respective family members can request
for any document at any time. Data Protection Act also amends that the families of
different patients can also ask for previous medical record even after the death of the
patient.
However, the data protection act also declares some key steps, which are needed to be
taken into consideration at the time of requesting for a medical record. The request for
medical track record is needed to be processed by a data controller. That data controller
might employed by some healthcare professional. Under the Data Protection Act
1998, patients need to write for requesting their previous medical records at certain
extension. However, in 2018 the act has been revised in such an order that allows
written as well as verbal request for geeing records. Additionally, under the current
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