Comprehensive Report: Record Keeping in UK Care Settings

This report provides an overview of record-keeping processes within the UK care setting, emphasizing its importance for healthcare delivery. It covers statutory requirements, including the Health and Social Care Act 2008, and highlights the need for clear, accurate, and timely records. The report examines the roles of various professional bodies, such as the General Medical Council and the Nursing and Midwifery Council, in setting record-keeping standards. It also discusses the process of storing and sharing patient information, including compliance with data protection laws and the sharing of confidential information. The report concludes by outlining the legal consequences of non-compliance with record-keeping regulations and stresses the importance of adhering to guidelines to avoid legal issues. The report emphasizes the role of record keeping in enhancing health and social services in the UK.

Care Setting

Contents
INTRODUCTION...........................................................................................................................1
MAIN BODY...................................................................................................................................1
CONCLUSION................................................................................................................................4
REFERENCES................................................................................................................................5

INTRODUCTION
Care Setting is defined in terms of a place where an individual receives health care services
for example- hospital, care homes with nursing, care homes. These services are not limited for
providing services in short run but also in long run facilities such as nursing homes, urgent care
centers and clinic services are included. This is an informative report that will provide
information regarding report and record keeping processes in a zone of service facility in care
setting structure in UK (Oladoyin and Adebayo, 2017).
MAIN BODY
Health care is provided by the British government and is funded by all the taxpayers. In
health care setting all the services and appointments provided are free to the patents. The UK has
a government sponsored universal healthcare system and that is National Health Service (NHS).
There is statutory requirement for keeping records in health care organizations but two reasons
that are very important above all are as-
 To assess the record of patient’s medication when required.
 To enable appropriate care to the patients both within and between services.
The records which are kept in care setting should to be clear, accurate, relevant and timely.
Medical and managerial staff creating or contributing to the patient’s record will provide timely
health records so that accountability can be determinant and it must also facilitate in decision
making. Health practitioners have a duty to keep up to date with relevant legislation's, case laws,
professional standards and local policies to keep record keeping standards (Record Keeping,
2019). As per statutory requirements electronic patients record system and medical devices in
accordance with local trust policy and procedures. Every entry recorded for patients must ensure
that they are clearly identifiable and each entry must be checked for accuracy prior to signing.
All the health records and local regulations throughout the life cycle of the record needs to
include management, retention, review and clearance. No unnecessary formation needs to be
recorded and all the information must provide a clear information of the transactions entered.
The Health and Social Care Act, 2008 regulations 2014 covers record-keeping
requirements under Regulation 17: good governance, paragraph 2. The Care Quality
Commission guidance on meeting part of Regulations 17 identifies the importance of service
users record being-
1

 Competitiveness, legitimate, fit for purpose, precise and updated.
 Security and confidentially must be maintained and it should be amended by an
individual who has valid authorization.
 Complete and accurate for anyone lacking mental capacity to take best decision.
 Keep in line with current legislation and guidance, particularly data protection laws.
The health and professional bodies also required to register staff to obey the current
professional record keeping regulations as required by the following governing bodies such as-
General Medical Council: As per this, council clinical records should include clinical
findings, decision which are made and actions which are agreed. Along with which, who is
making those decisions. Data provided to patients about any drugs prescribed and treatment
records (Devereaux and Gottlieb, 2012).
As per the council, clinical data recorded in reports must be maintained by the physician as it
is necessary to treat the patient. It may also be required for further medical or legal purpose.
 Health and Care Professional Council: After registering with this council various
professional responsibility needs to be kept full to keep clear and accurate records. The
records must be clear, accurate and legible and sharing of any information must be
recorded. No confidential information must be shared without consent and medical
records are made to support safe and effective care but may be used for other purpose.
 Nursing and Midwifery Council: The aim behind developing these records is to
facilitate with a clear and precise account of the patient’s health care journey so that it
can reflect the practitioner assessment, planning and analyzing process. It is based around
four themes which are prioritizing people, practice effectively, preserve safety and
promote professionalism & trust.
 General Pharmaceutical Council: The requirement of the council record and report
making is to fulfill statutory role to promote, protect and maintain the health, safety and
well-being of members of the public by upholding regulations and public trust in
pharmacy.
It is an important activity of developing and keeping records as the standards of assisting
health care professionals needs to fulfil the expectations of the trust and promote the best interest
of patients. Health and care record for the patients or client is an accurate account of treatment,
care planning and delivery (Chamanga. and Ward, 2015).
2

The process of storing records starts with identifying the relevant data that needs to be
stored in the record keeping process. Accuracy and viability of the data needs to be checked on
the basis of regulations that are provided through various council's regulating the care setting
sector. When the information is checked on the basis of formal regulations then it needs to be
recorded in the legal documents. This information in form of records are stored for a time
duration that is mentioned in the care setting rules and appropriate to give fair treatment to all the
patients.
All the health and adult social care organization must share information with each other
about patients by abiding respective it directly helps in enhancing health of patients. Health and
Social Care Act, 2015 was introduced to reduce anxiety about data sharing. Confidential
information needs to be shared with consent and by law when directed by court. In case of
benefits to a child or young person that will arise from sharing information both the public and
individual interest in that case also confidential information can be shared (Bemister and
Dobson, 2012). It is essential to share information for delivering better and more efficient
services which are coordinated by the requirements of patients. It is essential to enable early
intervention and preventive work. When information is shared within the organization or
between two organizations then the Care act 2014 does not apply for sharing of sensitive,
personal information where the public interest outweighs the public interest served to protect
confidentiality.
Information is shared lawfully within or among two organizations within the limits of the
Data Protection Act 2018. There must be a local agreement or protocol on place setting out
processes and principles for sharing information between organizations. All the employees
working in care setting organization must ensure that organizations policies must be maintained
while sharing information. The General data protection regulations are not a barrier of sharing
information as it provides a framework for sharing information and that information needs to be
honest. In case of doubt seek advice without disclosing the identity of the person. Information
when transferred needs to seek permission where appropriate with considering safety and
wellbeing of the person affected with the information. Transecting of information need to be
necessary, proportionate, relevant, accurate, timely and secure. When data is transferred record
needs to be maintained for the same (Bradshaw, Donohue and Wilks, 2014).
3

When information is transferred internally then there is no specific requirement for
transferring information. Details of the patients are transferred among the organization when it is
necessary to provide better treatment. When information is transferred among two organizations
then it must be checked that transferring of information is necessary for betterment of patient.
Together with this consent of the individual must be received who is going to be affected by the
transfer of the information. When information is highly confidential then it can be acquired
through law with order of court.
In case of non-compliance with the legal and statutory requirements of record keeping in
care setting the organization will be charged with the appropriate punishments which is
mentioned in the Health and Social Care Act, 2008. Organization can be legally sued by an
individual to whom the information belongs or by any regulating authority who is in requirement
of that information (Raza, 2012). When record keeping is not maintained properly by care
organization then regulations under which they are registered can remove invalid their
registration.
It is recommended for care setting that all the records need to be recorded properly and
maintained up to the time duration mentioned in the laws governing care setting. Information
when demanded by an individual or organization is provided when it is appropriate for better
results. Guides that are provided under several acts that guides care setting sector needs to be
followed to minimize any legal hurdle.
CONCLUSION
From the above project report it has been concluded that care setting sector helps in
enhancing health and social services in UK. This sector is governed by laws and acts that are
specifically designed so that health care sector can enhance. Records and reports in care setting is
maintained as per the governance of Health and Social Care Act, 2008. Information when
transferred internally and among two organizations must be followed through rules and
regulations for sharing information. Noncompliance with the legal requirements under care
setting regulations may lead to impositions of charges as per law.
4

REFERENCES
Books and Journals
Bemister, T. B. and Dobson, K. S., 2012. A reply to Mills. Record keeping: Practical
implications of ethical and legal issues.
Bradshaw, K. M., Donohue, B. and Wilks, C., 2014. A review of quality assurance methods to
assist professional record keeping: Implications for providers of interpersonal violence
treatment. Aggression and violent behavior. 19(3). pp.242-250.
Chamanga, E. and Ward, R., 2015. Documentation and record-keeping in pressure ulcer
management. Nursing Standard (2014+). 29(36). p.56.
Devereaux, R. L. and Gottlieb, M. C., 2012. Record keeping in the cloud: Ethical
considerations. Professional Psychology: Research and Practice. 43(6). p.627.
Oladoyin, V. O. and Adebayo, A. M., 2017. Community perspective of alternative methods of
keeping immunization records in a rural setting of southwest Nigeria. Journal of
Community Medicine and Primary Health Care. 29(2). pp.65-73.
Raza, M., 2012. Good Medical Record Keeping. International Journal of Collaborative
Research on Internal Medicine & Public Health. 4(5). p.535.
Online
Record Keeping. 2019. [Online]. Available through: <https://app.croneri.co.uk/topics/record-
keeping/indepth-0>
5