Analysis of Record-Keeping and Reporting in UK Healthcare Systems

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Contents
INTRODUCTION...........................................................................................................................1
LO1..................................................................................................................................................3
P1.................................................................................................................................................3
P2.................................................................................................................................................4
M1................................................................................................................................................7
CONCLUSION................................................................................................................................9
LO2................................................................................................................................................10
INTRODUCTION.....................................................................................................................10
P3...............................................................................................................................................11
P4...............................................................................................................................................13
P5...............................................................................................................................................15
M5..............................................................................................................................................17
CONCLUSION..........................................................................................................................19
REFERENCES..............................................................................................................................20
1

INTRODUCTION
The proficient record keeping and reporting serves as the backbone for any health/ or
care system. It not only helps in fluent working of the institution, but also aids in
achieving a commendable patient compliance through the accurate and reliable record
maintenance. The reporting of any iatrogenic errors, dangerous mishaps, recovery
status of the patient and prognosis of a disease to the higher authorities is of utmost
importance in a Health Care Setting. There are several arrangements designed for
ensuring the beneficial use of records with the institute internally as well as amongst the
inspecting bodies and sister institutes. As an efficient supervisor one must be sure
about the mode of storage opted whether it is manual or electronic. It must provide an
easy access to record sharing and disposing in accordance to the respective guidelines
and legislation whenever required.
2

LO1
P1
The statutory requirements of record keeping and reporting must be followed strictly and
righteously by the health care setting. One of the major guiding protocols in this context
is the one in accordance to the Data Protection Act 1988, wherein the rights and claims
of the patient and the duties and entitlement of the authorities both are described
precisely. Under the Data Protection Act 1988, the processing of the personal
information of the patient should be fair and lawful, the personal information should be
exclusively used for the purpose of record keeping and reporting any further use of the
patient’s information is not admissible (Iversen et al., 2013). The content of information
recorded should be precise and succinct in strict correlation to the patient’s purpose of
visit to the care system .The records should not be kept any longer after the
accomplishment of actual purpose. The processing of the information shall not violate
the patient’s civil rights. Effective and appropriate measures shall be devised for
intervention in cases of unexplained loss of information or any damage or any
unauthorized access to the information. The interstate transfer or sharing of patient’s
information is not admissible unless there is a sure affirmation with regard to the
protection of the information. Any sort of discrimination based on any grounds of
physical disability, chronological character i.e. age, spiritual beliefs, community, marital
status, race, or sex is a punishable offence as stated by the Equality Act 2010 (Baillie,
and Matiti., 2013). Thus, any partiality or unlawful handling of the patient’s records on
these bases is not admissible and all patients are equally treated by this law, providing
a Healthcare System which serves all civilly. Not only the proper reporting but also the
Health and Safety Act, quotes the minimal amenities that has to be provided by the
recruiter for ensuring the well-being, safety and health of the employees (Goetsch.,2010
). The accurate recording of the patient’s details and information is essential to ensure
safety.
3

P2
The constitution of the inspecting and regulatory bodies ensures the smooth and
uniform reporting and record keeping by citing various guidelines. The National Health
Service (NHS), the Care Quality Commission (CQC), the National Institute of Health
and Care Excellence are the prime inspecting bodies. The provision of quality health
care which is safe, compliant, effective and newest in the treatment modality is assured
by the several inspection carried by the CQC (Care Quality Commission., 2013) . These
inspections are unprompted, fair, and irrespective of the ratings of the health care
system. By the virtue of these regulated and periodic checks of the clinical accuracy
people are provided with the attested and accredited ratings of the health care
institutions by the CQC (Care Quality Commission., 2011). CQC is an organisation
which looks after the health and social care provision for adults in England. They have
devised the safe and fluent communication with the patient, confidential handling of
records, maintaining patients’ worthiness, right to safe treatment, respecting the
patient’s independent decisions the basic prerequisites.
4

The government of England utilizes the tax income to provide free and high quality
healthcare to the people (Waterson., 2014). The NHS specifies a minimum 10 years’
time to protect and keep the patients’ information, which starts after the patient’s death.
This ensures the renewal and replenishment of the Record in every Health Care System
in every 10 year (Barnett et al., 2012). The National Institute of Clinical Excellence is set
up by the government of England to ensure a high quality health care provision, efficient
drug delivery systems, quality life expectancy and harmonious social care for all
(Wonderling et al., 2011). The NICE also regulates a confidential maintenance of
patient’s disease, detailed instructions indented by the physician in charge, the status of
patient’s general state at the time of discharge which is to be secured and preserved by
the health care provider until the time specified by the NSH. The Healthcare System too
is equally prone to any mishap or disaster as are other workplaces or institutions, and
hence the proper reporting of any mishap or uneventful event should be done in
accordance to the predefined guidelines.
5

The parliament of the UK has especially deployed the Reporting of Injuries, Diseases,
and Dangerous Occurrences Regulations (RIDDOR) to govern the proper and just
reporting of such cases. Any sudden incident of disaster, or mid treatment fatality, or
any sort of medical negligence, or unattended fresh complaints of the patient in care
system, or any of the physician induced injury, or toxic drug reaction is to be
immediately and transparently documented with inclusion of every minute detail of the
incident such as time, place, events preceding the incident, after care measures, and
palliative care; presented and reported to the governing authorities through the
supervisor (Griffith, and Howarth., 2014).
6

M1
The aftermath of failing to meet the regulations set up by the regulating and inspecting
bodies might land the Healthcare Institution into great trouble in terms of disqualification
and refrainment of the license. The lack of compliance may be indicative of an improper,
unethical and negligent health care .The incomplete treatment record affirms an
incomplete address to the patients’ complaints (Patrick., 2014 ). The attending family
has all the rights to sue the Health Care System and its physicians under the name of
fraud and negligence. The grave impact of such instances blooming back in time
signifies the grey reputation and image distortion of the culprit Health Care System. The
non-compliance with regard to the reporting of any disaster or mishap other than those
related to the iatrogenic errors, often leads to misconception about the institute. The
thorough reporting of such cases aid in the statistical analysis of the success rates of
the institute. The Health Care Systems who fail to monitor a regulated and controlled
record keeping are often slammed with hefty fines against the state legislation. The
authorities such as the CQC also refrains the negligent healthcare systems from their
ranking schemes. The loss of information of a patient’ details, their health records can
subject the healthcare system to legal proceedings. The non-compliance of a doctor in
the form of withholding the patient’s information and reports is itself a punishable
offence.
7

Even in terms of the non-provision of the drug prescriptions and summary of discharge
might lead to the legislative actions against the health care provider. The breach of
confidentiality of the patient’s information and any instance of it being passed across the
states or institute is liable to the strict actions against the provider. In incidents of forgery
or any other tampering of the medical records the suspected health care provider or the
consultant physician is lawfully liable to the five years of imprisonment. The medical
records of the patients if exposed to the media without their consent then the health
care system handling the records are the sole element responsible for the leak. And this
is why they can be summoned by the court of law in any time sooner (Smith., 2018).
The negligent and improper handling of medical records which have caused a flaw or
false positive report for the research workers have to penalize and reimburse the entire
sanction for the research work. Any healthcare system which is unable to produce the
records and reports of a patient in time before 10 years of the patient’s demise is also
subjected to legal action and hence is supposed to present to the attorney for the same.
8

CONCLUSION
The proper functioning of a Health Care System and its sister institutes on a longer go is
directly proportional to their efficacy in record keeping and reporting. The institutes are
not only subject to the indented guidelines but also to the patients’ queries and aims.
The accurate measures of storing the patient’s personal details, their treatment
schedule, drug prescription along with the discharge notes comprise the wholesome of
their course of disease. Irrespective of the nature of patient, whether in patient or
outpatient these details are to be saved and kept secure for future references.
9

LO2
INTRODUCTION
The processes of record keeping and reporting in own health care setting should not
only ensure a fluent in-Centre communication but should also allow an efficient manner
in between the sister institutes, and fellow specialists all across the state. The sharing
of the personal information and treatment details of the patient should be transparent
yet confidential which is ensured via a leak proof channel of data transfer secured by
passwords and check posts in case of electronic and manual transfer, respectively. The
storage and record keeping should be in strict accordance to the recommended
regulations and guidelines. The reporting of all the incidents taking place in the health
care setting should be done immediately and in a regulated manner in order to avoid
any noncompliance judicial action.
10

P3
The process of storing record in own care setting may from maintaining a clear record of
their clinical details, treatment plan, drug dosage and its alterations to all sorts of
investigatory details in terms of pathological reports, radiological scans and surgical
samples or biopsies (Bondesson et al.,2013).The mode of storage might be in the form
of hand written scripts, computer generated reports, self-maintained log books, registers
or highly advanced electronically driven software based storage programs. The clarity of
recording the patient’s information is the true factor which dictates the processes of
efficient record keeping in longer go. Every minute detail regarding the patient’s vitals,
disease transitions, their previous medical/surgical histories/drug allergies, mid
treatment flare ups, details of drug dosage, dietary consultation, investigation, any
required surgical intervention or specialist consultation or external institute amendments
must be mentioned clearly in their records. In addition these, the discharge notes must
11

also be kept stored and preserved as for the future references of the patient’s general
status at the time of discharge and the treatment follow up (Wimsett, , Harper, and
Jones., 2014).
The recent advances in the era of technological revolutions and software innovations
has lead us to the dependence on electronic and computer driven systems for storing
the patient’s information and even for sharing them. The computer based systems of
record maintenance has many advantages such as speedy entry, easy access, long
term leak proof storage, safe and guarded sharing of the patient’s information to name a
few. The electronically aided software based systems ensure the storing of not only the
textual details of the patients but also the various investigatory scans, radiology and
palliative procedures In the forms of image files, videos and animations.
12