Effective Reporting and Record Keeping: Health and Social Care Report

This report provides a comprehensive overview of effective reporting and record-keeping practices within healthcare settings, emphasizing the significance of accuracy, confidentiality, and adherence to legal frameworks. It delves into the statutory requirements, including GDPR and Freedom of Information Act, and the role of regulatory bodies in ensuring compliance. The report explores data storage processes, both manual and electronic, within healthcare organizations like Surrey and Sussex NHS Hospital, highlighting the importance of maintaining patient privacy and data security. It also examines the consequences of non-compliance, the sharing of information within and outside healthcare settings, and the internal and external requirements for recording information. The report also details the current processes for storing and sharing records. The report concludes with a discussion of the importance of accurate record keeping in healthcare and the impact on patient trust and care.

EFFECTIVE REPORTING AND RECORD KEEPING IN HEALTH AND SOCIAL CARE

P1 Statutory requirements for reporting and record
keeping
• Record keeping and report making in any healthcare setting needs to
consider different outlines to maintain high level of accuracy, confidentiality
and related elements for patients (Prigoff, Sherwin and Divino, 2016).
• The presentation will cover important legislation required to follow to
maintain privacy of patients within healthcare settings.
• It will describe recording and data storing process within any healthcare
organizations. It will undertake Surrey and Sussex NHS hospital to reflect all
major implications of recording process.

CONTD..
Healthcare settings need to lay emphasis on certain legislative frameworks for
reporting and recording health data of patients (Solove, 2016).
For instance, art Surrey and Sussex Hospitals, physicians are required to maintain
privacy and confidentiality of patients arriving to settings.
Health carers and settings need to follow specific privacy laws designed by UK
government,
DATA PROTECTION
• For protecting the data feed into information systems of hospitals, healthcare
setting need to adhere with the principles of GDPR act and Freedom of
Information act.

CONTD..
Freedom of Information
• Freedom of Information Act (2000) also need to be comply within hospitals
to maintain the trust level of patients. As per this act, healthcare
professionals need to provide adequate information of treatments and clinical
measures delivered to patients by them (O’neill, Dexter and Zhang, 2016).
According to this act, patients inhibits full right to know all required
information related to medication and other activities
Human rights
• As per the Human Rights Act (1998), all the convention rights must be
provided to patients within any healthcare setting.

P2 Regulatory and inspecting bodies’ requirements for
reporting and record keeping
• Hospitals must have specified provisions of licensing within each of its
departments and services (Solove, 2016).
• For any healthcare settings like Surrey and Sussex, regulatory bodies
require proper health data and information entry with proper coding systems
need to be maintained.
• Data must be arranged within a fix chronological order to reduce the
instances of confusions while searching any report of patients.

CONTD..
• If hospitals and healthcare settings fails to comply all terms and conditions laid
down by statutory guidance and laws then involved professionalized may get heavy
penalized (O’neill, Dexter and Zhang, 2016). .
• It shatters the image of healthcare setting in market and hampers its growth and
development.

CONTD..
• If audits are not being continuously followed by hospitals, then regulatory may
cancel its license or take its quality certifications.
• The quality care of the hospital may get restricted as well there will low level of
interest persist within employees to stay connected with organizations (Solove,
2016)..

M1 CONSEQUENCES FOR INDIVIDUAL
• In compliance of legal or ethical framework will disrupt the trust level of patients
for the healthcare settings (Haque and et.al., 2017)..
• Patients will not be able to freely express their health issues or consult with health
professionals due to the breach of any legal mandatory provisions.

P3 PROCESS OF STORING OF RECORDS IN OWN
CARE SETTING
Each and every hospitals have different forms of storing patients and other health
records. For Surrey and Sussex hospitals highly involve software related to health
information to generate and store the required reports.
Process of storing paper documents
• Paper documents within healthcare settings can be stored digitally as well as
manually. For storing paper documents manually, all involved professionals need to
keep records in proper separate lock age systems (Prigoff, Sherwin and Divino,
2016).
• Clinical notes that are handled by physicians and nursing staff must be kept in a
proper room or shelf and it need be locked properly.
• Surrey and Sussex Hospitals, stores all manual patients' information in a different
section which is safeguarded properly.

PROCESS OF STORING PATIENT INFORMATION
• Patients' information such as their demography records, past history papers,
admission and discharge papers etc. must be stored in proper chronological
order.
• All care plans are stored by doctors and nurses by the help of medical
coding and filing systems (O’neill, Dexter and Zhang, 2016).
• Large hospitals like Surrey and Sussex follow strategic codes to pass the
messages and have separate digital HIS portals to communicate internally.

PROCESS OF STORING THE ELECTRONIC
DOCUMENTS
• Hospitals share store its digital data in specified database which is different within
each hospitals and maintained authorities body.
• For Surrey and Sussex hospitals, electronic health data are recorded by usage of
patients' past records and timely upgraded (Haque and et.al., 2017).
• Proper filing systems are followed within hospital information system that are
highly secured with advanced digital protocols.
• The hospitals have maintained high level of accuracy and security to store all its
electronic data.

PROCESS OF MAINTAINING CONFIDENTIALITY
• For maintaining the confidentiality the healthcare settings need to use secure digital
systems that must be operated by authorized person only.
• For instance, clinical records of patients must be checked and delivered by
physicians and health carers only (Prigoff, Sherwin and Divino, 2016).
• The systems that are being used must be locked properly and protected by
application digital passwords and lock systems.
• Furthermore, confidentiality of patients can also be maintained by adopting a
confidentiality policies related to patients' records.

CONTD..
• Apart from maintaining and storing health records, hospitals need to ensure
the level of accuracy that need to be performed during overall recording
process.
• Error within health data may alter outcomes and may lead to display
unprofessional behavior of personnel (Adler-Milstein and Jha, 2017).
• Disposal of data or medical records must be done after a specified time
period.
• There must be an official circulation proposed by hospitals before dissolving
the documents.

P4 Reasons for sharing information within own setting
and with external bodies
• Healthcare settings need to share patients' information to continue other
related clinical assessments.
• Hospitals need to circulate elementary health information to regulatory
organizations to facilitate it in generating required health status or lifestyle of
overall population of country (Solove, 2016).

CONTD..
• These data can also be shared by hospitals to research institute to prepare
necessary health related studies (Adler-Milstein and Jha, 2017).
• The presence or rate of any loopholes within healthcare system can be
analyzed by assessing health records at considerably large level.

P5 INTERNAL AND EXTERNAL REQUIREMENTS
FOR RECORDING INFORMATION
External and internal requirements that need to be present for smooth recording of
information are-
• For internal recording requirements, Medical history need be highly accurate with inclusion
of past history records of patients (Schaper and et.al., 2016).
• The information of all prescribed clinical tests must be complete. The related reports such as
incidents cases, surgical records must be prepared accurately.
• Along with this, hospital must maintain call log histories to manage and cross check the
contact timings of the staff.

M2: Current processes in own care setting related to
storing and sharing records
• Surrey and Surrex Hospital utilize all the technological support for effective
recording process.
• It follows all legal frameworks required while sharing and storing health
data.
• Health data are shared when the hospital are required to dissolve its old
medical records (Haque and et.al., 2017).
• Notifications of new births and death data are circulated for generation of
health statistics.

REFERENCES
• Adler-Milstein, J. and Jha, A.K., 2017. HITECH Act drove large gains in hospital
electronic health record adoption. Health Affairs. 36(8). pp.1416-1422.
• Prigoff, J.G., Sherwin, M. and Divino, C.M., 2016. Ethical recommendations for video
recording in the operating room. Annals of surgery. 264(1). pp.34-35.
• Solove, D.J., 2016. A brief history of information privacy law. Proskauer on privacy, PLI.
• Schaper aned et.al., 2016. Substance use disorder patient privacy and comprehensive care
in integrated health care settings. Psychological services. 13(1). p.105.
• O’neill, L., Dexter, F. and Zhang, N., 2016. The risks to patient privacy from publishing
data from clinical anesthesia studies. Anesthesia & Analgesia. 122(6). pp.2017-2027.
• Haque and et.al., 2017. Towards vision-based smart hospitals: A system for tracking and
monitoring hand hygiene compliance. arXiv preprint arXiv:1708.00163.

THANK YOU