Record Keeping in Healthcare: Regulations, Processes, and Benefits

This report provides a comprehensive overview of record keeping in healthcare. It begins by outlining statutory requirements for reporting and record keeping, emphasizing the importance of maintaining patient data for continuity of care, clinical audits, and resource allocation. The report then describes the regulatory and inspecting bodies within healthcare, including component authorities, HPRA, EMA, and FDA. It delves into the processes of storing records, including registration, protective markings, activity levels, and patterns of use. The report explains the reasons for sharing information within healthcare settings and with other professional bodies, such as for early intervention, managing risks, and complying with legal orders. It illustrates internal and external requirements for recording information, highlighting the role of technology in modern healthcare, including computerization of patient records and the benefits of involving service users in record-keeping processes. The report also addresses the importance of accurate, legible, concise, and coherent records, as well as the management of service user records in compliance with national and local policies and guidelines. The report concludes by summarizing the key aspects of healthcare record keeping and its significance in providing quality patient care.

RECORD KEEPING

Table of Contents
INTRODUCTION...........................................................................................................................3
P1 Statutory requirements for reporting and record keeping in own health care...................3
P2 Describe the regulatory and inspecting bodies in health care...........................................4
P3 Process of storing of record in healthcare.........................................................................4
P4 Explain the reason for sharing information with own setting and with other professional
bodies......................................................................................................................................5
P5 Illustrate the internal and external requirements for recording information.....................6
P6) Technology is used in recording and reporting in own care setting................................6
P7) The benefits of involving service users in record keeping processes..............................8
P8) Accurate, legible, concise and coherent records regarding service user care for different
service users following own setting guidelines......................................................................9
P9) Various aspects of own management of service user records with reference to compliance
with national and local policies and guidelines....................................................................10
CONCLUSION..............................................................................................................................12
REFERENCES..............................................................................................................................13

INTRODUCTION
The record keeping is defined as the keeping the data of any individual or group in a
confidential manner for any use in future. In health care the keeping of record of patient is very
necessary for organisation for maintaining the process, evaluation and medication and always for
medical history(Beaumont and et. al., 2016). It have set of action with many new technology in
storing data in electronic way and also with the context with paper. So this topic cover the
policies and other aspect of regulations.
P1 Statutory requirements for reporting and record keeping in own health care
There are different requirements for which the reporting and the record keeping is
necessary. Some of the requirements are discussed further.
Continue care easier- this is one of the most important one in which for providing the
better services. It can help in get the all information about the history of the patient which helps
in managing the care in such proportion. This can help in get the continue information of the
patient and can help in providing the better care.
Promotes better care information with other team- This one is the very useful reason
which can help the other professional which are related with the patients. Other professional can
easily get the current status of the patient (Sokol 2016).
Supports in clinical audit, research and allocation of resources- keeping record can help
in during the audit period when there is need to collect the data of different patient and also can
help in the research process like collecting data for statics.
Identify early risk and detection of complication- this is the one which can help your
doctors or other professional in getting or finding out when there is any complications in the
patient's health.
Supports in delivering services- In such type there is need to collect the data for
providing the services according to the need and the care which they require to. According to the
data they are eligible to make decision for providing the specific services to them.
Improving accountability- Recording keeping and recording can help in providing the
sufficient data which can help in improving the accountability which can be beneficial for the
patient and the health care department too (Haffajee and et. al., 2018).

P2 Describe the regulatory and inspecting bodies in health care
There are different regulatory and inspecting bodies in health care. Some of them are
discussed further in this report.
Component Authorities- they are the one who are having the legal ability to carry out
some certain tasks. They are the one who are responsible for introducing the national regulation.
They are also having the minister of health. They are the one who are able to manage the
authorizing process of medicines. They also manage the regulations of medicine sin the EU in
both human and veterinary (Jalali and et. al., 2018).
HPRA - It is known as the Health products Regulatory Authority which is an Irish-based
authority which was initially founded as the Irish Medicines Board. They only covered drug, but
now they also covers the medical devices and products. They are having the role to regulate
different health products, cosmetics and medical devices to drugs for the benefit of safety for
both human and veterinary practices. HPRA also produces the company licenses for distributing
and creating medicines in the market with close security and safety.
EMA- this one is the European medicines agency which relies on the different scientist
committees which are of paramount influence. Any of the pharmaceutical agency which
produces the new high-end medication in EU, they must need to scientifically reviewed by them.
FDA- Food and Drug Administration which is one of the biggest regulatory authority in
the world, which is an agency which is having the main supervisor for drug, devices, food and
cosmetics in the country. They are being a branch of HSS which employs about 10,000
professionals who are the safeguard in al large portion of the citizen health.
IMDRF- This is the International Medical Device Regulators Forum which was
established in year 2011, in October. It was established by involving the selection of medical
device regulation which includes the WHO (Wilson 2016).
P3 Process of storing of record in healthcare
This is most important in the healthcare to maintain all the data which is reports and the
record of each patient which are accessory when there is need to recheck-up of to get the
information of the patient's medical history. In this context they are no any guidelines which they
need to follow for recording of data of the patients. Different healthcare have their own process
for keeping the records in which some of are described below which at-least should be follow to
keep it safe for the record purpose.

Registration- In every healthcare department, this one is the first step which is necessary
to get treatment in that healthcare. It includes the all detail which can be used for identifying the
patient in future with the help of such registration data. Such as file title, year of opening or
treatment etc.
Protective markings- this is the one which is used to identify their patients in the future
references. This can help in finding the specific type of patient either for their medical
information or for the purpose of the research (Teasdale and et. al., 2017).
Activity level- this is the level in which all the activities of their patients is noted down
which can be helpful in the future in any other disease to get the information about their health
and related to their complication which can be possible to be their patients.
Pattern and duration of use- it is the one in which the pattern of treatment and the
medication is noted down with the time of duration in detail which is like from when to when the
patient was there for which type of treatment and who was the physician for him who was
treating that patient.
P4 Explain the reason for sharing information with own setting and with other professional
bodies
There are many reason for which the healthcare needs to share their information with
their own settings or with the other professional bodies. Some of the reasons are described
further.
For early intervention and preventative services- this is one of the main reason for which
there is sharing of the patient information is there in own settings. This can help in to understand
about any of the chances for any complication in the health of the patient. This can also helps in
prevention of any services which is not good for the health of the patient.
Sharing information when there is any harm to third party- In some health issues there is
some of the complication which can create the risk of others health like viral infections, chicken
pox etc. Which may create the risk of others health issues (Van and et. al., 2018).
Sharing information when there is court order- Here, every healthcare department need to
follow the rule that you have to share the patients information when there is order form the court
to share it with the authorised person or professionals. When one denied the order of court then
such health care needs to face the problem which will be legal obligation and can be taken by the
court itself.

Sharing information in serious situations- the information of the patient's should be
shared whenever there is any type of serious situation such as terrorist related actions, natural
disaster and some other incidents which can said to be the serious issues and the sharing
information related to patients which can help in to solve the issues. There can be many
situations which can be there which is related with the healthcare or their patients in which
sharing the information can help in resolving the conflict or any situations.
P5 Illustrate the internal and external requirements for recording information
There are many requirements for recording information. Some of them are going to be
discussed further.
In this, every staff of the health care management need to understand the material which
is related with the compliance with health care settings. It will be better for consulting the
legislation and protocols which one should know the requirement of internal and external record
in healthcare. It is seen that in the local hospital the authority of the hospital refuses to share the
information of the patient with their family. The family is having the authority to get the
information about the patient but to lack of compliance with the low they are not able to get
them. Internal and external recording make it mandatory to record the information either on the
paper or electronically as the documents. They must include the care plan of the patients,
nutrition, documents used for prescribing, medicines which were used. External recording are
used as the legal requirement which are need to be their for the recording purpose. The public
Record Act 2005 governs that it is necessary to keep the record safe by the all health care
organisations (Budhwar 2017). There is the record keeper who is responsible to answer to the
parliament and the management of the health care must manages the records. This can be said
that there is obligation and the responsibility of every health care professionals for getting
observe the accountability which they use the record to get the information of the patients along
with service user. Internal sharing can help in to learn about the patient health with other
physician about their regarding case which they need to get involve for the well treatment of the
patient.
P6) Technology is used in recording and reporting in own care setting
In this current years, the digitalisation and computerization is on peak. As per this in
health care the modern technology help to store the data of many of patient in various ways.
Computerization of patient record help to store the data for long. Generally increased at the

moderate rate and give a trend is like to consistent, particularly as technology improves and
becomes more effective and efficient in health care department. The enhancement of digital
technology in aspect with health care is increase because it provide much satisfaction and
reliability to patient and management. There are many or process which is going computer based
in health care are diagnose, treatment, medication prescription and record keeping. Usually
record keep with the aspect of healthcare is mandatory. As per the post of nursing, I
acknowledge the shortage of technological resources. So as per my responsibilities, I just provide
a way of acknowledgement to the various team to adopt the new technology which help to
organisation provide a better path in the patient compliance. In the sector of healthcare, there are
many number of patient are admitted in hospital or clinic for their treatment, which is very major
role usually played by nurses to care and make them a record about their dispensing, medication
and difficult complication when the patient feel (Hamet and Tremblay 2017). According to the
total scenario, I recommand some digitalisation in term of recording of patient, which help the
patient to know about their medical history and prescription which is usually prescribed by
doctor for patient which content the knowledge about the medicine and other factor which help
to change the medication and other factor which create in issue of health complication. I analysis
the importance of record keeping in hospital these importance are:
Serve the history of client/patient: The record keeping help the hospital or clinic to keep the data
for long as much they want. But due non technological aspect it is difficult to store data for long
in paper or physical documented form. So I just advise to the board of member and management
of clinic or hospital to adopt the technology. Which help to keep the medical history, medication
history, diagnose history, treatment history and also the financial statement of patient and also
provide the billing records concept with mode of computerization.
Evidence to support if legal issue are arise: usually in the department of health care the accused
of legal issue are arises many of time due to inappropriate medication, or diagnose in this case
patient want to take the legal action in that particular hospital or clinic form he face. I suggest in
the concern with reports the data is stored and when the situation goes complex then. The stored
data help to provide the brief history of that patient which used to say that there is no any false
medication or treatment is taken by hospital for patient (Leone and et. al., 2016).
In the context with nurses, I used to say to that as nursing staff it is help helpful in the
field of nursing to keep the thing updated like, Document is keep by which the service related

issue and other complication are handled and sometime is used to rendered the service. I keep the
record in such a ways and after a time while it help to show that the evaluation of progress. That
how slowly the patient or fast the patient recovers. Its help me to know about the patient and
their service if he us take form the other hospital and just check and change the overall scenario
if the patient is needed and provide the better service to patient while changing the aspect and
provide the improvement in future with that patient. It also provide me the opportunity to judge
the quality of heath when it will provided to patient in any complication case. And also what
kind of work is granted form the hospital for the patient. It help me to indicate the plan for
future.
P7) The benefits of involving service users in record keeping processes
This concept involve me to create the equality, equity and policy which is help to develop
the carer involvement in service planing. The involvement of user and carer service planning is
an start of initial objective to transfer the power form policy makers and the medical professions
to the public approaches. The benefits of user and the carer is service planning are divided into
two types: democratic and principle and service improving decision.
Benefits
Democratic principle: in the core of setting of prioritised and create the rational level of health
care service such as national health services, which include the user and carer in service planing
which help to motivated . For me its help in participatory democracy, public accountability,
transparency as per the aspect with healthcare and rational ways. Its also provide me a
involvement in which in acknowledge people for capacity for self-determination, providing them
with a say in the planning for the care of patient (Nancy and et. al., 2016). As I heard, the
healthcare of world interacting department such as world health organisation declare the Alma
Ata stated that people heave their own right and duty to participate individually and collectively
in the core strategies and implementation of their health care and for me its challenging to
provide quality of health and quality of health care. And this help me to encourage in make the
mutual services of planing increases their commitment to understanding the patient compliance
and seeking to influence which create the factor that affect them in measurable way.
Service improvement: as per my perception the user involvement help to improve the quality of
health of public health activities such as patient have issue with long term disease or illness often
have insight about their care and procurement that health care provider and found some error

from the quality of policy which is called the lack of quality. Users and carer not facing the same
conflicts as medical staff or representative and policy developers, who usually contributing in
financial interest in healthcare services and health services. Involve in the creation of a
partnership between the technical experts and public (Papadopoulos and et. al., 2016) And also
help in potential of service user which have access to lead to more accessible and acceptable
health services, health research of higher quality and clinical and higher uptake in finding.
Barriers: medical professional are always socialise with other and they take themselves as
authorities. The users and carer have many of biased views on some health issues like media
reports on the MMR vaccine which affect the vision and prospective of patient on vaccinations.
The involvement make the healthcare intervention project longer in duration and higher in cost.
User and carer have not interest in contributing as per my aspect as a nursing assistants it is
difficult to make sure about the presentation from the whole vision of society, which individually
help to those groups which are traditionally hard and difficult to reach. User have lack in
technological knowledge, which may affect the degree to which they can participate. These are
the aspect of barrier which show the degree of user and carer involvement and various path of
supporting it. My prospective in this is, the user involvement can achieve the view of individual
user or group which can be initiated by user professionals.
P8) Accurate, legible, concise and coherent records regarding service user care for different
service users following own setting guidelines
My view on the recording is that it is major asepct of providing a social work which
include the tools like gathering, organising, and observing key information which help to inform
decision making and planning (Pedraza and et. al., 2017). Reflecting upon this and analysing
information in order to develop and adjust the new plan and strategies, elaborating the openness
with service users and help in providing the evidence regards with service user and evidencing
their lives and view and involvement, maintaining the total accountability of firm, and also help
in transferring the information form one to another organisation. This document have objective
to provide the set of recording standards which enable employee to records information in
continuous manner. The data is stored in paper format or electronic system. In my aspect the
social worker taking all the regulated responsibilities for completing their social works and the
records are maintain in such as way which is timely comprehensive and of good quality and must
therefore lead the policy. I usually see the quality recording which help the employee in such a

way such as providing documents which is evidence based of authority,s involvement with
particular health service provider users, providing the basic knowledge to help with their
analysis include service/care planning and reviews and evaluations, provide the core of
continuous working by changing the shift and are being absent, giving the knowledge which is
based investigation, complaints and feedbacks., providing service user with a fulfilled records of
their care and in some case. Whereas, all the records are finalised within the three regular
working days of that events, until a appropriate standard operating procedure include a different
time scale. The main objective to recording this as per my sense is to collecting the information
in concise way. Where all information and contacts about ongoing work with individual or
others. Additional paper files are contain the document that need to be taken in their original
papers. Such as birth certificate and legal paper documents which setting outs the orders include
placements orders. I just found many of policies which is based on the record keeping and their
aim but as per the standard guidelines in which as in my department there are some policies
which are access to files, case transfer policy, case file audit policy, one to one and supervision
policy, life story work policy and procedures, emails and internet policy (Ross and et. al., 2017).
In my department there are various principle are followed for the record keeping which are
provide accuracy, clarity, relevance, timeliness, legibility, responsibility, services users
involvement, care must be taken when the recording is taken and make sure that the data is
confidential and the principle within in data protection act 1988 are used in this, when emailing
or faxing the relevant information about service user, any emails uploaded to the documents tab
on protocol which used as irrelevant communication between the sender and the recipient.
Confidentiality which is necessary for keep the patient record hide form the distrustful people,
sharing of information, management sighted must be evidenced, staff include their full name,
recording of decision making, sharing of case records (Seriani and et. al., 2016).
P9) Various aspects of own management of service user records with reference to compliance
with national and local policies and guidelines
A record keeping in my preference is to collect the data by information management
program also known as RIM which help to manage the their physical and electronic records
throughout their life cycle. As I discussed in today's that the rise of information rise which is
ever changing the regulatory environment, its became a necessity for companies to implement
continue strategies to improve the core of health care and accountable records management

standard. By creating the well structured record management plan, the organisation have meet
their regulatory achievable meets which improve the workflow and limits itself to exposed the
risk.
Set-up a records retention routine: as I seen today life the digital environment are grown fast
in various forma. Many of companies still approach to save the time and data which is being
used in the digital platforms which include the perform a records storage of all physical and
electronic records, establish a standardized records classification system, conduct research on all
federal and local requirements.
Policies and procedures: the management records program have a policy to support in aspect
with legally and operationally. The policies and procedures set the standard for a feedback
management system which include the continuous improvement. I must include the management
of all records and media types which is being used nowadays. Including the direct email process.
In healthy care every aspect of this is followed to make sure that data is being stored with respect
with policy. The policy may divided in different for records retention, actives files, emails and
several others area of information management.
Accessibility, indexing and storage: in my contrast, contributing aspect make an effect of a
successfully record management program which have ability to access your data when the me or
other person needed. Organisation need to obtain many of data for fast for everyday business
process and their requirement (Shivappa and et. al., 2016). The electronic data of recording help
to stored the data form long time which is present also in internet through the portal and if
anyone need to see it they access by their private key. This technique or method is called online
data management.
Compliance auditing: to achieving the path of success of an enterprise records the management
system which will never be achieved if employee are not complying with firm record
management policies and process. This same process is followed by the management of
healthcare to keep the data in record for the future use. The elements of a records management
audit should include the retention schedule complies with up to date legality and total law with
regulations, indexing accuracy and flexibility of documents, training and communication with
among staff and department. Protection and preservation of records and their keeping, timely and
consistent deployed of inactive files.

Disposal and obsolete records: once I recognised my files in system then I just determined the
right of retention policy. Then the time arrive to dispose the non needed data or document. It
include determine the type of program suitable for your media or document (Tomasello and et.
al., 2019).
CONCLUSION
As per the above discussion, this topic indicate the overall aspect of healthcare and how
they keep their records, there are number of process to keep the records, and how effectively the
records are driven and make it confidential from other. The records are kept is such a form where
some accessible person are authorise to take it. The policy are driven in the records keeping
which is mentioned above. These all help in the patient safety and improvement of better service
and core.