Analysis of Record-Keeping and Reporting in Rose Meadow Care Home

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Contents
Lo1...................................................................................................................................1
Introduction.................................................................................................................1
P1.............................................................................................................................. 3
P2.............................................................................................................................. 5
M1..............................................................................................................................6
Conclusion.................................................................................................................. 8
Lo2...................................................................................................................................9
Introduction.................................................................................................................9
P3............................................................................................................................ 10
P4............................................................................................................................ 11
P5............................................................................................................................ 12
M2............................................................................................................................13
Conclusion................................................................................................................ 13
Lo3.................................................................................................................................14
Introduction...............................................................................................................14
P6............................................................................................................................ 15
P7............................................................................................................................ 16
M3............................................................................................................................17
Conclusion................................................................................................................ 17
Lo4.................................................................................................................................19
Introduction...............................................................................................................19
P8............................................................................................................................ 19
P9............................................................................................................................ 21
M4............................................................................................................................22
Conclusion................................................................................................................ 23
Reference......................................................................................................................24

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Lo1
Introduction
Record is defined as a document that is permanently written and it communicates
about patient's health and social cares status and management ((Gill Kamath and
Gill., 2012)). In health and social care sector reporting is considered very
significant as well as necessary, as the different types of reporting have the
follow a different set of policies and regulations in order to deliver better health
and social services to the individuals within the society. Records and reporting
don't just help in an easy and fluent working system of the organization but it
also helps in maintaining accurate and reliable patient records for future
references. In the health care sector it is of utmost importance that the proper
records and reporting regarding the past history of patient is done appropriately
which might include any surgical procedure, any mishaps, the recovery status
after injury or prognosis of disease all these information helps in planning the
future treatment for the patient and also helps in providing proper quality of
services to the patient. In order to attain proper and ensured records that can be
very beneficial many arrangements are done for such things internally as well as
with reference to sister bodies and inspecting departments. A supervisor in the
rose meadow care home, its the duty to have a proper mode of storage of the
collected data and records may it be manual or technical they should be easy to
excess so that sharing or disposing of information can be easily done whenever
required. It also helps in making proper treatment plans for patients by
multidisciplinary team workers. This essay focuses on the requirements in
reporting and health keeping as well as about the prime inspecting bodies to
verify if organization are working under the guidance of juidiciary.

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P1
In the health care setting, the statutory requirements of reporting and record-
keeping are to be followed very appropriately and strictly keeping in mind all the
rules and regulations of the firm or organization (Sinsky et al., 2013). The data
protection act, 1988 is found to be one of the major protocols for any guidance.
Where the right of the people of the society are described precisely along with the
duties and actions of the authorities are well defined. The data protection act,
1988 signifies that the personal information collected by the patients should be
recorded fairly and appropriately and kept in records and this information should
only be used when in case of any medical emergency or need any other use of
this personal patient information is considered illegal. The records should not be
kept for a longer time once the patient treatment is completed and information
processing should not affect the civil rights of the patient. In order to keep the
patients record safe and secure general protection act, 2018 was introduced in
reference to the nurses and health care staff of the European Union
(Raghupathi,.and Raghupathi., 2014).
In rose meadow care home the patient’s records are jotted but they are not kept
safely or they are not reported in the correct way. It required conducting regular
basis of inspection by CQC and NHS, the organizations that work for the welfare
of the patients to ensure that the records of the patients are well organised and
are secure enough for any misuse under the set guidelines. These organizations
make sure that the patients have safe and fluent communication; they have the
right to have safe treatment and make sure of the patients' decision (Noe et al.,
2017). The rose meadow care home should train the professionals in such a way
that they are capable of understanding the importance of the data collected by

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the patients and how they should be reported in a way that the records are not
misused or touch any one's personal space.
The requirements for record keeping are: records should be clear and legible,
they should be complete, no ambiguous abbreviations to be used, no informal or
slang language to be used, entries should be done with respect to the correct
patient, not be tempered. The importance of statuary requirements for keeping
records is that for the system to work efficiently policies and regulations are
important to be jotted down, the appropriate system with proper accuracy and
affectivity is required, good quality of records is equivalent to quality assurance,
the record-keeping process is made more effective and reliable if the
requirements to attain is fulfilled appropriately (Francis., 2013).
The requirements for reporting are: confidentiality should be utmost prior, any
information to personal should not be reported with outpatient consent, having
safe custody, proper language while reporting, their records should be managed
properly while reporting. The importance and impact of the statutory requirement
for reporting are statutory reporting promote better service quality, it also helps
in understanding the incidences and hence the reporting is done appropriately,
the cases of misuse are avoided within the system (Wager, Lee and Glaser.,
2017. ).

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P2
The prime inspecting bodies include (NHS) National Health Service, (CQC) care
quality commission and the national institute of health and care excellence.
These inspecting authorities have a basic role in ensuring smooth and uniform
record-keeping and reporting within the various provided guidelines. The
inspections, which are carried out by the CQC are to evaluate the safety,
compliant, effectiveness of the services and the application of the newest
treatment course by the respective organization (Kaufmann., 2017). The
inspections carried out are made sure that they remain fair and unprompted
ignoring any ratings of the health care organization. The rose meadow care home
needs to improve their quality of standards and the basics of their record-keeping
and reporting of the personal information collected by the patients so that they
can be provided with the attested and accredited ratings after the inspections
done by the CQC.
Government of England uses the taxes paid by the citizen to provide them with
free and good quality of health care. NHS specifies the time of minimum 10 years
to keep the records safe of the patient and this time starts after the patient's
death hence the renewable of records data takes place in every 10 years of time.
The national institute of clinical excellence set by the government is to make sure
the life expectancy quality of patients (Francis., 2013), peaceful social care,
proper and appropriate delivery of drugs to the patients. NICE also helps in
maintaining the confidentiality of the patient records with respect to any disease
or status patient

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M1
Non-compliance is described as inappropriate service delivery that does not
matches the quality of standards of services or practice and it does not fit in the
set guideline by the authorities. It is the violation of the policies or rules made in
accordance with the patients' protection and safety of life and information. Any
there may be various mild to severe consequences faced on failing to comply
with the regulations of requirements of bodies with reference to record-keeping
or reporting. The regulatory bodies to evaluate and monitor the effectiveness of
services provided by the organizations conduct inspections and to check if they
follow the policies formed by the bodies. When the organization fails to fulfil the
expected services, regarding reporting and record keeping as per the guidelines
of national and local legislation, this results in non-compliance (Council, F.R.,
2012.).
The result of non-compliance by the organizations is: punishments and penalty
can be charged to the respective organization for not complying towards the set
standards and also for the harm caused to the patients because of this,
punishment can be given to any health care official if he is involved in any such
case of patient, other results of non compliance is charging heavy penalties,
enforcement of legal notices, and even cancellation of working license. As a

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result of non- compliance by the rose meadow care home CQC can cancel their
licence if they do not improve their services within 6 months. Consequences due
to non- compliance by the organization on the patient as an individual is such
that they lose the trust in the organization (Gambelli et al., 2014), loss of respect
and dignity, and privacy issues other than this individual can also face social
stigmatization and humiliation by the society due to the release of the personal
information by the organization.

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Conclusion
The efficacy in maintaining appropriate records and reporting is directly related
to the proper functioning and quality services providing by the health care
organizations and their sister branches. Similar criteria go for the rose meadow
care home as its high time they take the safety and security of patients seriously
in reference to maintain records and reporting. Patient's choirs and aims are
equally important with following the intended guidelines set by the authorities. It
is required that in order to maintain the decorum of dignity and respect the
records of patients should be kept secret and not be easily accessible.
Inspections by CQC and NHS should be conducted to monitor the information.
And also keep a check on the quality of services provided by the organizations to
the patients. The set of rules and regulations should be followed by every
organization else the authorities have a right to punish them or take a heavy
penalty from the organization and also in worst cases the working licence can
also be called. As patients, personal information is very important and cannot be
revelled publically as patients might later feel disrespected, or can be stigmatised
by society.

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Lo2
Introduction
The record-keeping and reporting processes which are done in own health care
centre or setting should be maintained with equal efficiency with other sister
institutes along with this an easy and fluent communication within the centre
should be maintained also with the other specialist the tracks should be
monitored. A leak-proof data channel that is secured with passwords and security
check post in case of manual and electronic transfers is used to transfer the
information of patients and their treatment details as the information should be
transparent along with confidential. Appropriate guideline with proper rules and
regulations should be followed in reference to the records keeping and data
storage. The reporting of each incident should be done immediately with any
alteration which takes place in the health care setting and it should be made sure
that it is reported in a way that it follows all the rules and regulations in order to
avoid any kind of non- compliance with respect to the judiciary.

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P3
Storing of records means maintain a data of records in own health care setting in
accordance to the details related to the clinical issues, treatment plan of patients,
dosage of drugs, all sort of investigatory details with might include radiological
report, pathological reports or scans, MRI, biopsies etc. the mode of storage in
own health care setting might be in reports written or verbal forms, logbooks,
registers, electric record manager, clinical notes, documents, incident report and
meeting reports. When the patient information is recorded or noted with utmost
clarity the recode keeping will be highly efficient in the longer run (Wu Ahn and
Hu., 2012). It is important to write every minute detail of patients responding
health with might include the pulse rate, temperature, flare-up, drug dosage, diet,
surgical and past medical history, recover rates, drug allergy, investigations
these things are recorded on daily basis for patients future treatment and future
references. With the advancement and evolution of technologies and software’s
we are now dependent on the computers and applications completely and these
have advantages of having accurate work, speed, easy entries, leak-proof with
passwords and the storage can also be done wit radiological images and scan of
various investigations (Bennett, Jensen, and Basch., 2012)

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P4
In the own health care setting, it is important that the records of the patients are
stored safely and in order to transfer information, it should be transparent as well
as shared in a highly confidential way. Under data protection act, 2018 and the
health and social care act, 2012 the patient's records can not be misused and it
can be shared without the informed consent of the patient and rightful purpose as
it can lead to disrespecting the dignity of the patient (Carey., 2018. ). The purpose
of sharing the internal and external data of the care home to the charitable
organization is only for quality purposes, as they have a right to ask for the
respective data regarding the care home because they fund the care home and it
is their responsibility to check with the quality of services provided by the care
home. It will also help the organization to identify areas with high risk and
improvement scope thus enhancing the overall quality of the care settings. Both
internal and external recordings would be used for the purpose.

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P5
The patient’s information should be recorded since the day that they get entry till
the last day of discharge, which should include the whole treatment plan,
diagnosis, investigation etc. the internal requirements for record-keeping in own
care home include: care planning, recording past medical history, diagnosis,
clinical planning's, investigations, service user forms, feedback forms, telecare
recordings etc. and these can be done with proper patient trust, good
communication skills, skills of data recordings (Patel et al., 2015). While the
external requirements for record keeping are: report of various injuries,
accidents, other dangerous mishaps or occurrences these are to be recorded
accurately keeping in mind the policies and legislation to be maintained under
health and safety at workplace act. These requirements are also in accordance
with the NHS guidelines and CQC frame of quality assurance it could also be
helpful for external audits and quality accreditation. These recording will also be
helpful in any medico regal issues that might arise at the care centre.