Analysis of Effective Reporting and Record Keeping in Healthcare

This report provides a comprehensive overview of effective reporting and record-keeping in a healthcare setting. It begins with an introduction that emphasizes the significance of accurate and comprehensive documentation for patient care, legal protection, and communication among healthcare professionals. The main body of the report is divided into two tasks. Task 1 explores statutory requirements, regulatory bodies' expectations, processes for storing records, reasons for information sharing, internal and external recording requirements, and the implications of non-compliance. Task 2 focuses on the use of technologies in reporting and record-keeping, the benefits of involving service users in record-keeping, the importance of accurate and legible records, management of service user records, and the effectiveness of technology in meeting service user needs. The report concludes by summarizing the key findings and reinforcing the importance of maintaining detailed and secure records for quality patient care and regulatory compliance. References are also included to support the information provided.

Effective Reporting and
Record Keeping

INTRODUCED......................3
MAIN BODY..................................................................................................................................3
TASK 1............................................................................................................................................3
Statutory requirements for reporting and record keeping in own care setting............................3
Regulatory and inspecting bodies' requirements for record-keeping and reporting in care
setting...........................................................................................................................................4
Process of storing of records in own care setting........................................................................5
Reasons for sharing information within own setting and with external bodies...........................5
Internal and external requirements for recording information in own care setting..................6
Implications of non-compliance with legislation, regulating and inspecting bodies’
requirements................................................................................................................................6
TASK 2............................................................................................................................................6
Use of technologies in reporting and record-keeping in own care setting..................................6
Benefits of involving service users in record keeping processes................................................7
Accurate, legible, concise and coherent records..........................................................................8
Different aspects of own management of service user records...................................................9
Effectiveness of use of technology in terms of meeting service user needs................................9
CONCLUSION..............................................................................................................................10
REFERENCES..............................................................................................................................12
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INTRODUCED
Record keeping and reporting are synonymous. An effective patient care needs
documentation of future plans, treatment and diagnosis so that, sharing of communication for
every practitioner for benefit of patient. Several civil cases develop after initial event, records are
important to provide content, accuracy, clarity, style and comprehensiveness. In a record
everything should be mentioned such as date and sign. Aim of record-keeping should be accurate
and non- offensive and should not breach patient confidentiality (Stavropoulou, Doherty and
Tosey, 2015). It can be either hand written or can be maintained with the help of electronic
devices. This assessment will include legal and regulatory aspects of record keeping and
reporting and also how technologies are used to keep record and reporting.
MAIN BODY
TASK 1
Statutory requirements for reporting and record keeping in own care setting
Clinical record keeping and reporting is integral part in a good professional practice and
provide a good quality of healthcare. Clinical record-keeping and reporting should change
continuity of care and also enhance interaction between different professional of healthcare.
Accurate written record and report detailing every aspects of the patient monitoring is essential
not because it forms integral part of provision of nursing management or care of patient but also
it contributes to circulation of information among different teams interested in patient's care or
treatment. A legal sense, record-keeping and documentation is also there for protection of
healthcare professionals or healthcare. The new General Data Protection Regulation is that Data
Protection Directive, underpinned by number of principle of data protection that drive
compliance ( Wuellner and Bonauto, 2014). GDPR requires that data controller provide data
subject with the information about patient's personal data processing in concise, intelligible and
transparent that easily accessible and different from other task between data subject and
controller using plain and clear language.
Any organisations which publishes, analyses and collects confidential health and
information of care should follow codes of practice on confidential information. It defines steps
which organisations may and should take ensure, confidential information handled appropriately.
This code will help organizations to put right procedures and structures in place so front line staff
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can follow the confidentiality rules. It gives a good practice guidance for those individuals who
are responsible for meeting and setting organisational policy on handling of care information and
confidential health like board members. These types of requirements are essential to reporting
and record-keeping, it helps to maintain a good quality of data and information about all the
patients which is required to maintain. This information is required for any policy development
and implementation.
Regulatory and inspecting bodies' requirements for record-keeping and reporting in care setting
Keeping records and reporting is important patient and care employees. It is vital which
staff are given training for reporting and record keeping, which is need to update and referring.
The Fundamental Standards that national healthcare system has to apply in order to maintain
registration of service with care quality commission. These are designed to maintain reporting
and record-keeping. The code of ethics and standards of the professional conduct is ethical
benchmark for the investment professionals around globe. The CFA institute code of ethics and
professional conduct are the fundamental to values of CFA institute. Inspecting body
requirements are essential in healthcare. By inspecting care people help to ensure if healthcare
services which are meeting needed standards of care and this good practice is recognized and
areas of betterment are addressed. These inspectors are undertake unannounced and announced
inspection of the healthcare services. This involves physical inspection of clinical areas and also
interviews of patients as well as staff (Feng & et. al., 2014). Care quality commission regulates
all social care and health services in United Kingdom. This commission ensures safety and
quality of care in healthcare. This commission provides care at home with help of trained staff
who collect the whole information about the patient and keep it safe for their care and treatment.
Healthcare can face implications if it fails to comply a good care and service. And it is
very important to maintain a proper information about patient and patient's medication. If
healthcare fails to provide it can lead to enforcement notices, legal actions and monetary penalty.
Enforcement notices are type of notice which are received by healthcare in case inspection
inspector comes and investigate and does not find proper care and data management of patients
at that time this notice is sent to that healthcare. Health and safety executive launched
investigation into Ramsay health care in UK, it was because of the internal occupational health
service was run. And healthcare has to pay some amount as a penalty in such cases and also
some legal action can be taken against the particular healthcare.
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These types of notices and actions can have negative impact on the healthcare as patients
have faith and trust in health care which can be loss due to such actions. Patients may loss
dignity and reputation among patients. So every healthcare has to maintain a proper data and
patient information data which has to be safe.
Process of storing of records in own care setting
Reporting and record-keeping in NHS has its own procedure to maintain information
about all the medicines and treatment. Record keeping include the computer and paperwork
records which need to be kept safe. The data can be record in computer or written in papers.
These records contain patient's information such as nutrition recording and care plan which
include all the information about patient's treatment and medicine which are given to the patient.
And other documents like laboratory reports, text messages, emails and letters to and from other
profession are stored in electronic device which come under the electronic documents.
Information database of all the x-rays, tape recording of telephone conversation, photographs and
videos are essential for the healthcare to record. These information can be required in any case
related to any patient or to extract other information. Types of information includes name, date
of birth, age, sex and address which has to be keep confidential. And confidential information is
a type of information which is shared with only a few individuals for designated purpose. This
information can not be shared with other people because in that case there are chances to misuse
information for the personal gain (Smith, 2016). There are different types of confidential
information like contact details of family, bank information, medical record and history,
assessments and personal care issues. This information has to be record in a secure system.
Errors can be occur in reporting and keeping records which do not affect outcomes but certain
mistakes can be fatal and dangerous. So the errors and mistakes has to be avoided as much as
possible. Retention and disposal of record contain clear record destruction and disposal
guidelines like destruction of any media containing protected and sensitive information which is
required to ensure that external media has to be clean and disposed.
Reasons for sharing information within own setting and with external bodies
Information of any patient is not required to disclose but there are some reasons due to
that NHS has to give the information to their family members who are needed. In this case it has
to discuss with patient and then it can given to personnel. In case patient has to change care
centre or shifted to other healthcare, it can be given to the other professional who is going to
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provide care or treatment. And also it can be given for public health investigation which helps to
investigate the data about patients (Watterson, Walsh and Madeka, 2015). ICO data sharing code
of practice for example express obligation which is referred to individuals have rights to some
basic services and provisions meeting these type of needs places obligation on others. A patient
has to right for moral and legal obligation to provide competence and safe healthcare. Expressed
powers are directly granted to federal government found in constitution and implied powers can
be reasonable assumed through expressed power. These powers are required in NHS to provide
safety and security to the patients in United kingdom.
Internal and external requirements for recording information in own care setting
National healthcare system has internal and external requirements for reporting and
record-keeping.
Internal recording requirements: Internal record-keeping requirements are tests, treatment
and medical history. For example surgery records, diagnosis, complaints and clinical incidents
has to recorded and has to maintain with safety. These requirements are important to provide
treatment to the patients. Maintaining timing of entry and exit with the signature.
External recording requirements: It includes health and safety which is required during
incidents and accidents. It include health and safety at work regulation which provides safety to
staff of healthcare (Morrison & et. al., 2019). Reporting diseases, injuries and dangerous
occurrence regulations include the reports about the such events with staff and patients, which
provides health and safety.
Implications of non-compliance with legislation, regulating and inspecting bodies’ requirements
Regulating, legislation and inspecting is very important in NHS. It provide safety and
security to the patient's personal information because it can be misused for personal gain so it is
required. Maintaining proper reporting and record-keeping is important in every healthcare
which provide accuracy and detailed information which is required for the patient's treatment.
TASK 2
Use of technologies in reporting and record-keeping in own care setting
Reporting and record-keeping is important in NHS, these records can be maintain by
using different technologies which helps to keep data safe. And it gives many benefits such as it
can be easily access information about any patient by using certain codes, which helps to save
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time. It can be safe and can be given to other professional use in case of treatment and care. It
also provide a secure care to patient because the every medicine and other laboratory reports are
included in these information. Patient's record system is type of clinical information system that
dedicated to storing, making available, storing, collecting clinical information important to
delivery of the patient care. The main focus of these technology is clinical data and billing
information or not financial. It is used in UK to capture data at point of care. And also to
combine data from multiple external and internal sources as well as to support the caregiver
decision making. In healthcare technology is used in form of tablets and phones to record the
vital information about the patient. These technologies provide a proper care to the patients who
are seeking for treatment. Co- producing value in case of healthcare starts from fact that
clinicians and patients exists within larger system which can promote toward optimal care. Every
patients can choose what kind of care they want and information can access about patient only
when it is required (Zeff & et. al., 2016). National Institute of Health and Care clinical guidelines
are advised on approximate care and treatment of individuals with specific condition and
diseases within NHS in UK. They are based on best available aim and evidence to improve
quality of healthcare by altering process of healthcare. And also improving chance of people of
getting well as much as possible. It provides recommendations for care and treatment of
individuals by health professionals. The information can be access as per the need. Technologies
which are used in NHS are very secure to use.
Benefits of involving service users in record keeping processes
Using technology to maintain records and reporting about the patient and staff. Reporting
and record-keeping both are important in NHS because it helps to record every confidential
information of patient and also care, which required to keep in healthcare. These type of
technologies which are used to record information give flexibility to users. It can be easy for
users to access information whenever it is required which also save time and confusion. Using
technology for the keeping information gives accuracy to users (Haberer & et. al., 2015). This
information can be shared with the other professionals and family as per requirement. Sometimes
patient has to shit to other healthcare in that case history of patient can access easily and shared.
It also saves resources, keeping paperwork can need more employees and can create confusion.
These services also have certain barriers which can create hurdle for the digital working.
Barriers include cost, software updates, ethical issues, lack of skills and training implications.
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Maintain the systems can be expensive for the particular healthcare. These technologies need
some basic training to access system which can be a barrier for the healthcare. Every user who
has to maintain the data need skills to operate system. Sometimes people can lack with these
skills which can have negative impact on these services. The software needs to update because if
not, it can be easily attacked by virus and sensitive information can be taken. Sometime system
can be hacked by the other users which can make healthcare to loss of every confidential
information. These are the challenges that can face by a healthcare while keeping records and
reporting.
Accurate, legible, concise and coherent records
Accurate and clear record support patient care and clinical decision making. It is required
to document every patient interaction as soon as possible. It is also important to maintain
integrity of record and it can be used to evidence in any event for claim or complain. It is a
reminder of the things happened during actions, outcomes, step taken and consultations because
no one's memory is inerrant. Evidence can be provide if standards of care is called into any
question. A well maintained record has up to date information about every patient and their
treatment that should be accurate, clear, timely and concise (Beckey and Fanelli, Intelli-Services,
Inc., 2015). So it can be easily understand and access. There are typical types of records which
are used to record information in healthcare such as time sheets, minutes of meeting, rotas,
recording progress and change as well as recording nutritional status. Time sheets and rotas are
used to keep record of patients and visitors which require the exact timings in terms of minutes.
There are sheets which record the changes in condition of patient or any king of progress which
helps to choose treatment and particular antibiotics. Recording such type of information can be
useful for the healthcare, they may need it any time.
Recording timings of patient and visitors is required in healthcare. The information which
is written in record has to be clear and concise so it can be understood properly in case of access.
Keeping records and reporting makes healthcare more flexible. It will be easy to search any
patient's details with the particular information. And it also help to provide care that patient
needs. These records can keep information about the previous health history and treatment which
are important for further treatment.
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Different aspects of own management of service user records
Numeracy is ability to use and understand numbers in daily life, which is essential but
understudied component of the literacy. Task related to numeracy are common in healthcare
which include understanding interpreting blood sugar readings and nutritional information and
understanding probability in the risk communication and also adjusting medication. Numeracy
and literacy are strongly correlated. Many patients are identified with adequate reading ability
but with poor numeracy skills. Numeracy is very important in healthcare. And it is also required
in day to day life. If in NHS any kind of data is required to record, in such case numeracy is
required so it is an essential part of day to day life (Louise Lemieux, Gormly and Rowledge,
2014). Management of nutrition and fluid intake is an important component of healthcare and
has to be taken care in NSH. And checking patients that are adequately hydrated is very
important part in healthcare. They should know the every detail of nutrition and fluid which
taken by a patient and keeping record of it is required to provide a good care and treatment.
Every patient require some amount of nutrition every day and which has to consume by that
particular patient which provide a progress and changes in patient’s body.
Physical inactivity makes person inactive and unfit so for every patient has to do some
physical activity daily, which will make them physical and mentally active, not doing any
physical activity can make person stressed, obese, and depressed and can make suffer with the
other diseases. So this is an important part in patient’s life. In healthcare care provider should
motivate patients for physical activities.
Effectiveness of use of technology in terms of meeting service user needs
Technology use in healthcare is very important because it helps to maintain record of
patients and every detail about the patient’s treatment which is required in every healthcare. By
using technology patient information which has to confidential can be maintained and which is
needed to prevent the misuse of the information (Darvishpour, Joolaee and Cheraghi, 2014). Any
system can keep such records which can not be access by others, only users can access and
provide it to professionals when it is needed. The documentation of every patient has to be done,
it also come under reporting and record keeping. Every detail of patient is need before the
treatment and also when it is progressing. The changes which has taken place has to be recorded
it will help to professional to provide further treatment and care.
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Daily observation and recording every little thing is essential in NHS, it gives the
information about whether patient getting a proper care or not. If there is any issue with the care
it can be improved. Recording the all antibiotic and treatment which is given to patient so they
can show the report when it is needed, so proper management of records are required in
healthcare. Reporting and record keeping is used in healthcare of UK which provide the security
and safety to patients.
CONCLUSION
From the above information it has been concluded that reporting and record keeping is
essential in NHS. These records should be clear, concise and accurate. The information has to be
confidential, revealing to other professionals for treatment and family. To keep records
technology also required which makes it very easy and flexible. There are several disadvantages
and also barriers of using technology. Record keeping and reporting are required in every
healthcare so it has to be maintaining properly.
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