Healthcare Record Keeping and Reporting: Requirements and Procedures

This report provides a comprehensive overview of healthcare record keeping and reporting. It details the statutory requirements, including data protection regulations (GDPR) and the Freedom of Information Act, that govern the handling of patient information. The report discusses the roles of regulatory and inspecting bodies like the Care Quality Commission, emphasizing their importance in maintaining standards and ensuring patient safety. It explores various methods of storing records, such as paper documents, incident reports, and electronic databases. Furthermore, it examines the reasons for sharing information both internally and externally, highlighting the importance of patient consent and the obligations of healthcare professionals. The report also outlines the internal and external requirements for recording information, including medical history, test results, and treatments, as well as adherence to relevant legislation like the Health and Safety Act and the Management of Health and Safety at Work Regulations. The report concludes by emphasizing the critical role of accurate record keeping in healthcare settings to improve patient care and ensure compliance with legal and ethical standards.

Healthcare settings record and report

Table of Contents
INTRODUCTION...........................................................................................................................3
TASK 1............................................................................................................................................3
P1 Describe the statutory requirements for reporting and record keeping in own care setting. .3
P2 Regulatory and inspecting bodies’ requirements for reporting and record keeping in a care
setting..........................................................................................................................................4
P3: Describe the process of storing of records in own care setting............................................4
P4 Discuss the reasons for sharing information within own setting and with external bodies. .5
P5 illustrate the internal and external requirements for recording information in own care
setting..........................................................................................................................................7
CONCLUSION................................................................................................................................8
REFERENCES................................................................................................................................9

INTRODUCTION
Healthcare is the important approach that support to the people related the medical
treatment. It is an essential for healthcare organization to manage their records in proper manner.
Healthcare setting includes but not limited to acute the heath care services for long time. This
report will discuss about the statutory requirement for the reporting and also keep records of own
cares. This assignment will discuss about the process of storing the records. Furthermore, there
are different type of regulatory and inspecting bodies which required for keep protecting the
records or information. There are many reasons for sharing the information within the own
setting and external bodies.
TASK 1
P1 Describe the statutory requirements for reporting and record keeping in own care setting
Statutory requirement is a type of compliance's such as conforming a rules and regulation
such as standard laws, specifications, policy etc. The compliance describes the specific goals and
objective of organization that inspire to achieve the objectives. This legislation's are to be ensure
that they are aware about the policies and regulations. Recording keeping is the important for
both patient and healthcare organization (Cheng and et.al., 2018). Staff members are given
training in record the information in proper manner. It also realizes that the regulation directly to
keeping accurate care about own records.
General data protection regulations and principles (2018)- This law was passed by the
government that help for healthcare organization to protect the information of patient. In this
way, people is also keeping their ow records. According to law, healthcare must follow when
managing, processing and collecting the personal records of people by using this law.
Freedom of information act (2000)- This act was passed by the parliament of united
kingdom that create right to access the information (O’Callaghan and et.al., 2018). It is
implementing the freedom of keeping records their own cares. It provides the freedom of every
one to access the records held by the public authority. It is the new statutory law that required for
keep records the information related the healthcare
Human rights Act (1998)- This act is mainly set up the fundamental rights and freedom
of everyone in UK. It is required for public bodies such as healthcare and hospitals that carrying
the public functions to respect or protect the human rights.

Data sharing code of practice (2016)- This statutory is applied to share the personal
information. It helps for providing the goo practice advice that will be relevant to the healthcare
sector. A group of healthcare exchanging the information about the medical who were
disrespects.
P2 Regulatory and inspecting bodies’ requirements for reporting and record keeping in a care
setting
Regulatory and inspecting bodies are required for people to maintain their fundamental
standards related the healthcare (O’Hara and et.al., 2018.). The regulatory is necessary for the
inspection of statutory in which control the agencies, confidentiality and impartiality etc. these
are the important concept that perform different function related the public safety at the time of
promotions. It also helps for keep maintain the records of own cares setting.
Professional Standards and Codes of Conduct- The code of ethics and standards of
professional conduct is a type of ethical bench-mark for the investment all across the world.
Healthcare staff members and people must comply with the legislation, rules and regulations
(Papuga and et.al., 2018). They also know about the rules to participate for managing their equal
rights. In healthcare, employees have duty and responsibilities to maintain the loyalty to their
patient and also must act with the reasonable cares.
Care Quality Commission- The care quality commission is a non departmental public of
healthcare department to manage the social care of people. Main role of commission is provided
the safety and security service to the patients. It encourages improving the high quality of care in
proper manner. This type of car quality is to monitor and inspect the wide range of data source
that can indicate the issues with the services.
P3: Describe the process of storing of records in own care setting
Storing and managing the records are the method that used for protection, disposition,
organizing and retrieval the information in proper manner. In the healthcare, it is needed for
patient to manage and store records by using different methods.
Paper documents clinical notes- This is the best method for stored the information of
patients. It is a traditional method whereas all the medical certificate and other nodes store in the
clinical notes (Saleem and et.al., 2018). The purpose of accurate and complete patient records
maintain in the form of documents. It also creates a communication between the service's

provider and members those who will know about the status of health, treating planning and care
delivery etc. For Example- nutrition, care plans etc.
Incident reports and statements- This report is includes about the injuries such as
circumstances of incident. It also stores the date, time, location where accident happen. The
purpose of incident report to records the accident and filled out the form in order to unusual
event that occurs.
Information systems/databases- It is a type of electronic medium to store the information
about the patient such as x-ray, photographs, tape recordings of telephone conversations, video
etc. Healthcare organizations always maintain the information by using database system (Singh
and et.al., 2018). It is an approach to easily collect all the information and generate accurate
result through electronic mode.
P4 Discuss the reasons for sharing information within own setting and with external bodies
Information sharing is a process that express their feeling towards the external bodies for
the purpose of development. An effective sharing of information among the practitioner and
healthcare agencies are essential for identifying the need and provide the service related safety
(Smith and et.al., 2018). There are various reason for sharing the information to the external
bodies.
Identifying objectives- This is the first reason of sharing the information to another
because the main objective of patient to identify the best treatment to the healthcare organization.
Many other professionals are providing the best quality of healthcare services.
Consent from user and their advocate- Each and every user can access the information
and records in proper manner. It is required for maintain the privacy and security. Healthcare
organization is applied the policy in their system. This will help for protecting the personal
information of patients.
Express obligation- In order to express the idea of obligation in the requirement of
information sharing. Employees has responsibilities to records and another person should
understand the advice related the innovative in information sharing. Many patients are aware
about the responsibility to keep maintain the records and share details trust worthy service
provider.

P5 illustrate the internal and external requirements for recording information in own care
setting
Internal and external requirements are essential for healthcare and patients to maintain
their information in proper manner. It is needed for established in the procedures to define the
control that manage an evidence of information system.
Internal recording requirement-
Medical history- Each and every healthcare organizations are maintained the records of
patients and their medical history. It is an essential for internal requirement to store the details
such as name, location, medical, diseases etc (Smith and et.al., 2018). it is an overall
documentation of particular patient.
Tests – Medical test is consists of report to show all the relevant information stores
related the patients.
Treatments- staff members are stored the records of patients those who are participated as
medical checkup.
External recording requirement-
Health and safety Act (1974)- It is a primary piece of legislation governing at workplace.
In healthcare, It implements the piece of regulation which are integral part of organization to
managing the health and safety. External recording is required to use this law for storing all
information in proper manner.
Management of health and safety at work regulations (1999)- This regulation were
introduced to reinforce of the management of safety and safety at workplace. This law has
applied on the healthcare organization where employee can maintain the health and safety. Main
duties under the regulation includes identifying the risk of related the health and safety.
Reporting of injuries and diseases occurrences regulations (1995)- This law is required
for employers and people who are control their own premises and report the specified incident at
workplace. It helps for understanding the pattern in injuries and accidents to be considered when
undertake risk assessment.

CONCLUSION
As per discussion, it concluded that Healthcare setting always keep records all the
information in proper manner. It is a crucial for healthcare organization to manage their records
in proper manner. Healthcare setting includes but not limited to acute the heath care services for
long time. It summarised the statutory requirement for the reporting and also keep records of
own cares. This assignment discuss about the process of storing the records. There are different
type of regulatory and inspecting bodies which required for keep protecting the records or
information. There are many reasons for sharing the information within the own setting and
external bodies.

REFERENCES
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care? Findings from a UK multicentre survey study. BMJ Qual Saf. 27(9). pp.673-682.
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Singh, P. and et.al., 2018. Healthcare providers’ perspectives on perceived barriers and
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