Compliance and Efficiency in Healthcare Record Keeping: A Presentation

Desklib provides past papers and solved assignments for students. This presentation details record-keeping methods in a care home.

Method of maintaining and keeping records in
the care setting

Table of Contents
• Slide 3- Introduction
• Slide 4- Accurate, legible, concise and coherent records
regarding service user care for different service users
following own setting’s guidelines
• Slide 5- Different aspects of own management of service
user records with reference to compliance with national and
local policies and guidelines
• Slide6- Process of maintaining records in own setting,
identifying any potential or actual difficulties
• Slide 7- Conclusion
• Slide 8- Reference List

Introduction
• The use of technology in record keeping will
be reviewed in the context of own care setting
• A demonstrating will be given on maintenance
of records in accordance to local and national
policies.

Accurate, legible, concise and coherent records
regarding service user care for different service users
following own setting’s guidelines
• In Riverview Care Home, computer-based patient record is
used to keep accurate and coherent records. In order to
review data of the clients, a Primary Patient Record is
used.
• Data such as age, birth date, address, and MRI or X-Ray
reports are well documented and can be used for
observations later.
• This is in accordance with the guidelines set in Care
Quality Commission. Under Regulation 20, it has been
stated that care providers should keep legible data in the
care setting

Different aspects of own management of service user
records with reference to compliance with national
and local policies and guidelines
• In order to comply with the local and national
guidelines in the care home, it is ensured that data is
recorded in paper, optical disk as well as computer
card.
• This is the method of data management employed in
Riverview care home.
• Since, a range of people and care settings such as
public health clinics, hospitals, nursing homes or
dentist offices uses the data it is ensured that proper
maintenance guidelines has been followed.

Process of maintaining records in own setting,
identifying any potential or actual difficulties
• From my experience at a care worker in
Riverview care home, I can state that problems
might also arise with the format of the data.
• In certain cases, when the generation orderliness
of the care setting get disturbed, it might have a
direct impact on the medical records.
• This deficiency is prevalent mostly when large
number of service users has to be catered at the
same time.

Conclusion
• I was given the responsibility of providing
training to newly employed staff regarding the
use of technology in maintaining patient records.
• Hence, technology based recording in own care
setting has been reviewed and trainees has been
presented a brief idea or demonstration of
working in line with national policies as well.

Reference List
• Scott, J.M., Beene, M.S. and Phillips, T., 2015. Understanding barriers and
facilitators to the use of Clinical Information Systems for intensive care units
and Anesthesia Record Keeping: a rapid ethnography. International journal of
medical informatics, 84(7), pp.500-511.
• Singh, H., Schiff, G.D., Graber, M.L., Onakpoya, I. and Thompson, M.J., 2017.
The global burden of diagnostic errors in primary care. BMJ Qual Saf, 26(6),
pp.484-494.
• Sridhar, D.S., 2017. Impact of Healthcare Informatics on Quality of Patient
Care and Health Services. Productivity Press.
• Sturrock, N.D., 2017. Communication in Medical Records. ABC of Clinical
Communication, p.35.
• Swinglehurst, D. and Greenhalgh, T., 2015. Caring for the patient, caring for
the record: an ethnographic study of ‘back office’work in upholding quality of
care in general practice. BMC health services research, 15(1), p.177.