Unit 17: Effective Reporting and Record Keeping in Healthcare

This report, focusing on Unit 17: Effective Reporting and Record Keeping in Health and Social Care Services, delves into the crucial aspects of maintaining accurate and compliant patient records. It explores the use of technology in recording and reporting within care settings, highlighting its benefits in reducing errors and improving efficiency. The report emphasizes the advantages of involving service users in record-keeping procedures, such as increased accessibility and improved patient outcomes. It provides guidelines for producing accurate, legible, and concise records, adhering to specific setting guidelines. Furthermore, the report examines the management of service user records, referencing compliance with national and local policies, including CQC regulations, safeguarding policies, and whistleblowing policies, as well as local initiatives like the Bolton Care Record. The report underscores the significance of record keeping for providing comprehensive patient histories and ensuring appropriate patient care. The report also addresses the importance of adhering to data retention policies, and the need for continuous improvement in governance and scrutiny practices.

UNIT 17 Effective Reporting
and Record Keeping in Health
and Social Care Services.

Table of Contents
Assignment 1...................................................................................................................................1
Assignment 2...................................................................................................................................1
INTRODUCTION...........................................................................................................................1
MAIN BODY...................................................................................................................................1
P6 Illustrate how the technology is used within recording and reporting within own care
settings....................................................................................................................................1
P7 Illustrate the advantages of involving service users in the record keeping procedures... .2
P8 Produce an accurate, legible, concise and coherent records regarding service user care for
different service users following own setting guidelines.......................................................3
P9 Explain different aspects of own management of service user records with reference to
compliance with national and local policies and guidelines..................................................4
Conclusion.......................................................................................................................................5
References:.......................................................................................................................................6

Assignment 1
Covered in PowerPoint presentation.
Assignment 2
INTRODUCTION
The health-care is very important part in every individual life. The record keeping of the
patient details are very essential for the correct treatment of the patient in the hospital. There are
so many importance of the record keeping of the patient. This includes that it would provide
accurate, honest and clear view about the patient history. This report would explain about the use
of technology in recording and reporting service user care (Keshta and Odeh, 2021). It would
also explain about how to keep and maintain records in a care establishment. This would also
outline about the legislations and national policies that is necessary to be followed by the care
setting establishments while recording the data of the patients of the hospital.
MAIN BODY
P6 Illustrate how the technology is used within recording and reporting within own care settings.
Well-being information technology generally presents numerous opportunities for
enhancing and transforming the well-being care that consist decreasing the human errors,
enhancing the medical results, ease the care coordination, enhancing the practice efficiencies as
well as tracking the information with time. In addition, the technology can be used to gather
information from people, such as their heart rate, sleep information, stress levels and oxygen
levels. It can be done via mobile applications as well as wearable devices such as smartwatches,
however, it does not need a care worker to manually take like reading. It is generally essential to
remember that as technologies improves as well as decrease the requirements for various face
interactions among care staff as well as the service users, the fundamental care standards as set
out in the care settings should always be maintained towards give high quality, a person-centred
care every time.
The records enhancement of the patients can make a high contribution in order to
effectively enhance the well-being care system of the country. With help of effective technology,
an automated records of the vulnerable patients can specifically enhance the delivery of well-
being care giving the clinical personnel with greater access of information, faster retrieval of
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information, greater data quality as well as more versatility in the display of the information.
With help of effective technology, an automated records of the patients can also encourage the
decision-making process as well as the quality assurance activities and give the medical
reminders in order to assist within the patient care. Furthermore, an automated records of the
patients can increase the results of research programs by electronically capturing the medical
data for determination. Moreover, an automated patient record can improve the efficiency of the
healthcare by effectively decreasing the costs and enhancing the productivity of care staff as
well.
P7 Illustrate the advantages of involving service users in the record keeping procedures.
A record system of the patient can be a part of the healthcare information system, that
more typically handles both the administrative as well as the medical operations or the clinical
information system. It can be described as the set of the formal arrangements by which the fact
mainly concerning the well-being care of patients that are being stored as well as stored and
processed within computer system. A patient record system is generally a type of medical
information system, that is effectively dedicated to gathering, storing, manipulating as well as
making available medical information generally essential towards the delivery of patient care.
Including the service users more potentially can lead towards more accessible as well as
acceptable well-being services, the well-being study of higher quality as well as the medical
relevance and a higher uptake of the specific findings. The involvement of the service user also
has been linked with the positive medical results like enhanced confidence and self-esteem and
the therapeutic advantages mainly outcomes from an enhanced social interaction. The possible
benefits of including the service users within the record keeping procedures such as transformed
well-being care services, an electronic well-being records are generally the initial step towards
the transformed well-being care (Service user involvement: impact and participation: a survey of
service user and staff perspectives, 2014).
The advantages of an electronic well-being care records can consist: a better well-being
care by enhancing all the aspects of the patient care, consisting effectiveness, safety, patient
centredness, education, communication, efficiency, timeliness and equity. Within this, the better
well-being by supporting the healthier lifestyles within an entire population, consisting enhanced
physical activity, avoidance of behavioural risks, quality of nutrition as well as broader use of
preventative care. In addition, enhanced efficiencies as well as reduced well-being care costs by
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encouraging the preventative medicine as well as enhanced coordination of the well-being care
services and by decreasing the waste and redundant tests. In this, the involvement of the user has
also been linked with positive clinical results like an enhanced the self-esteem and confidence
and the therapeutic advantages outcomes from an enhanced social interaction. Despite such rapid
enhanced in the awareness, the involvement of the service user has been struggled to overcome
the specific challenges linked with the translating the participation and empowerment of rhetoric
within the practice (Engaging patients in decision-making and behavior change to promote
prevention, 2017).
P8 Produce an accurate, legible, concise and coherent records regarding service user care for
different service users following own setting guidelines.
The record keeping is very essential in every hospital. This is because it provides a
detailed view about the history of the patient. There are various legislations that has to be
followed while recording the data of the patient in the record book. The methods to record these
data is also been given under the legislations. The NHS data is to be recorded as per the given
directions. According to NHS, the records should be held in such a way that allows access as
well as audit that is to be carried out. It would also create as well as log quality information.
Moreover, the information can be used when it is required by the hospital authorities and patients
as the case may be. It would also store the record in an approachable place for staff that requires
to know about it. Moreover, the record can also be used for the PPV folder.
There is also an option of Care and support plan. It can be used for anyone who needs
care of the patient information. This is also for anyone that cares for another person as well. The
care and support plan specifies about the type of support a person requires in an establishment.
This means a person can stay as autonomous as possible. Moreover, the individual can have as
much control over his life as possible it also specifies about the things a person enjoy. It would
also explain about the type of care which is right for the individual (Kim, et.al, 2019). Moreover,
it would also understand about the health condition as well as the care needs. Furthermore, it also
helps the family and friends to understand how it could help them. The care plans are established
to ensure about the patient who gets the similar care regardless of the members of staff on the
duty in order to ensure under which the care given is recorded by the administration.
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P9 Explain different aspects of own management of service user records with reference to
compliance with national and local policies and guidelines.
The general examples of policies of record keeping in the hospitals includes the no
smoking and vaping. It also includes the social media policy at the workplace. The policy should
be uniform. The attendance and time off policies should be given by the administration of the
hospital. The equal opportunities policy should also be followed by the selected institution. It
should also be safeguarding, whistle blowing and complaints of the individuals. It would also
give access to records. The National policies and regulations include the following-
• CQC Regulation 17: The purpose of this regulation is to provide that the providers have
systems and procedures which ensure that it is able to meet the requirements with this part of the
Health and Social Care Act 2008 Regulations 2014. So, in order to meet this standard, the
providers should also have an effective governance that includes the sureness and auditing and
procedures related to it. It must assess, display and drive betterment in the quality and safety of
services provided, including the quality of the experience for people using the service. The
systems and processes must also assess, monitor and justify any risks associate the health, safety
as well as welfare of individuals by using services, etc. Providers must generally evaluate and
seek to better their governance and scrutiny practice.
• Safeguarding policy: the Safeguarding vulnerable adults can be explained in the Care and
support statutory counselling issued by the Care Act 2014. these are the protecting the rights of
grown up to live in safe environment, free from abuse as well as free from neglect. The people
and institutions working jointly to prevent and halt both the risks as well as the experience of
abuse (Kshetri, 2018).
• Whistle blowing policy's: The whistle blower policy in United Kingdom is aimed to protect the
interest of generic public. Workers who reveal fraud, corruption and mismanagement to senior
administration is known as the internal whistle blowers. Workers who report the fraud or
corruption in the media, public as well as legal authorities are known as external whistle blowers.
Local policy's
Following are the local policies as follows-
• Bolton Care Record: This is the new private computer record which would permit health and
social care experts who directly involved in the care to approach the most updated information
about the individual.
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• RBHT this is the retention and disposal policy. This is the Police and Crime Commissioner for
South Wales who has committed to operative in an open and clear way. Moreover, in order to
follow with the Freedom of Information Act (FOIA), the Commissioner should make sure that
the records are in an adequate state of preparedness to meet the regulations which is necessary to
deal efficaciously with FOI requests. Moreover, the retention schedule is planned to support the
Commissioner’s corporate governance model and complies with the regulations which is needed
by the Information Commissioner. This takes into account different legislative necessitates.
• Bolton Council: This is also called as the Bolton Metropolitan Borough Council. It is the local
control of Metropolitan Borough of Boltonin Greater Manchester which is located in England.
This is the Metropolitan Borough Council out of which one of ten in Greater Manchester and one
of 36 is in the Metropolitan Counties in England. Moreover, it provides for the majority of local
government work in Bolton Metropolitan Borough of the country (Zarour, et.al, 2020).
Conclusion
This report would conclude about the recording of the data of the patient in a medical
establishment. The record keeping of the patient details are very essential for the correct
treatment of the patient in the hospital. It also summarises about the importance of the record
keeping of the patient. This report too explains about that the record keeping would provide
accurate, honest and clear view about the patient history. It would also explain about how to
keep and maintain records in a care establishment. This would also outline about the legislations
and national policies that is necessary to be followed by the care setting establishments while
recording the data of the patients of the hospital.
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References:
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Online:
Engaging patients in decision-making and behavior change to promote prevention, 2017
[Online] Available through: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6996004/
Service user involvement: impact and participation: a survey of service user and staff
perspectives, 2014 [Online] Available through:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4212124/
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