EFFECTIVE REPORTING AND RECORD-

KEEPING IN HEALTH AND SOCIAL CARE

Introduction

Collection of records is critical for care managers and their employees, although time-

consuming and sometimes unpleasant. We need to maintain a lot of documents that relate in

some way to the well-being of users, but not always necessarily. Because it cannot be

prevented, an effective program meeting all legal specifications is useful. This includes record

keeping to be viewed as a complete program that is designed, controlled, analyzed and

enhanced in its totality. In certain ways, this is to the advantage of service customers. For

example, clear reporting illustrates clinicians and service users' needs and is less likely to lead to

misunderstandings and errors. Good equipment will ensure that service customers and

maintenance manager would handle their appliances and devices properly and would have less

risk of breaking up and endangering the health of them.

TASK -1

Statutory Requirements for Reporting and Record Keeping

Common Requirements

All controlled services are protected by the guidelines given in Prompt 21A. The following

specifications are laid down by Prompt 21A.

Care records

Care services must be able to show that:

 Maintain records of the care and treatment of any service customer.

  The documents are used to plan and clarify the diagnosis and care of the individual as

needed.

 They hold that record updated

 The recording is done promptly, accurately and factually.

 The recording takes the privacy and security needs of the victim into account, i.e. never

will it be violent, judgmental or reproachful.

 The documents shall contain sensitive information on a patient's history, diagnosis and

care from other industries and agencies.

 Call information, including word of mouth information, such as telephone calls, on the

care and treatment of service users (Murphy, 2019).

Storage and Security

Records are kept safe, and consistent protocols are in place to access and to exchange

information between caregivers and care providers and other agencies. If the care service is not

available it will also have to plan for the required acceptable duration of preservation to be held

safely, e.g. three years for records of care (Adegboyega, 2019).

Access to records

The service recipient or his legal agent involved with his diagnosis and recovery will have

information available, for example when someone has no intellectual ability to make judgments

about his or her care and treatment and the staff. Therefore, everybody should know where the

documents are kept and how they can be obtained, and, if possible, should be able to help. Any

request for the record of a person should be answered in compliance with the provisions of the

1998 Data Protection Act.

 Requirements of Regulatory and Inspecting Bodies for Reporting and

Recording

Care Quality Commission Requirements

The legal requirements for record-keeping are specified in Regulations 20 of the Health and

Social Care Act 2008 (Regulated Activities) 2010. The first part of the Regulation explains why

records are required by service providers who do not have any relevant information would

jeopardize their service users' health, welfare and safety, who will not then benefit from their

services (Qiu, 2019). The criteria for preserving such types of documents are divided into two

parts. Caregivers must maintain accurate records of the person who needs the service, along

with correct documentation in Regulation 20(1a). Care providers shall maintain in Regulation

20(1b) accurate records of the personnel working in the provision of service (i.e. staff records)

and service management. The regulation does not specify which records for management

purposes are required. It is also clear that other documents are often needed by certain laws

and regulations that extend to all business entities (such as health and safety records). Other

criteria for record keeping are found in certain aspects of the compliance process (e.g. policies

and procedures). After the criteria for preserving such records are laid down, Regulation 20

focuses on how the records are to be preserved. In 20(2), any record, paper or electronics must

be held safe, but can be accessed immediately if necessary. For an "acceptable" time, a record

should then be kept and securely destroyed. The regulation provides the basis for a record-

keeping system which enables caregivers to be legally compliant and to take care of all relevant

aspects as laid down in Regulation 20. This is also endorsed by the Outcome 21 guidance:
Enforcement Guidance Records: Critical Quality and Safety Requirements. Take the Regulation

as a whole.

Implications of Non-compliance with Legislation, Regulating and Inspecting

Bodies’ Requirements

In the UK, companies which violate regulations may end up paying a range of prices, certain

that are specific and simple to calculate and others that are less quantifiable, but nonetheless

real (Cornock, 2019). The consequences of non-compliance with regulations

Defines six kinds of violations in the former category:

 De Minimis – The least severe form of breach is a technical violation, which has no

direct health or safety effect.

 Other-than-Serious – Infringement of anything related to health or safety that does not

lead to serious injury or death. An example is an employer that does not bring required

safety records into a job. Up to $12,934 in fines may be levied per violation.

 Serious – When a worker has knowledge that the health or safety of his workers is

compromised by an environmental threat, he does little to fix it. Up to $12,934 in fines

may be levied per breach.

 Willful – Given for a deliberate lack of quality. The offense, with fines up to $129,336

per violation and potential prison for people, becomes a criminal offense if an employee

is killed.

 Repeat – Provided for a violation similar to or equivalent to a violation previously

reported by an employer.
  Failure to Abate – Released if a situation about which it was quoted was not addressed

by an employer. Employers have a limited time to fix items. Failure to do so would result

in a fine of up to $12,934 a day.

Employers may face legal bills to cover lawsuits brought by injured workers, the properties of

employees killed due to a crime, and other potential fines other than penalties. In an notorious

example, British Petroleum (BP) has to date run up over $13 billion in lawsuits, advances and

damages in the explosion of the 2010 Deepwater Horizon oil plant and its consequent

environmental catastrophe. However, maybe the greatest cost is reputational harm. If the

health and safety requirements of a business are not met, customers, partners and the general

public are justified in getting them looked down on. This can lead to reduced revenue, firing,

bankruptcy or even company decline. Reputational damage, sometimes years to recover from,

if ever, can be serious (Gibson, 2019). A recent survey of executives by the American Society of

Safety Engineers showed that there was about $3-5 in indirect costs for any direct costs

incurred on injuries, which places the total costs of an incident at some between $45,000 and

$75,000 (with a direct health costs and a $15,000 insurance costs).

Task -2

External and External Recording Requirements

In this situation, the new workers need to learn information about the convergence of health

and social services. In order to clarify the criteria for internal and external care registration, the

regulations and guidelines must be revised. When the patient was dead in the recovery room,

the local hospital declined to share the health record with the family member. Although the
member of the family has the patient's civil rights, there is no proof that the situation is

inconsistent with the law. As a consequence, internal and external health monitoring criteria

are discussed in this section (Adegboyega & Musa, 2019). It is necessary to know all aspects of a

person, including the physical and mental well-being (Ashurst, 2019). It is important to maintain

the record so that a patient is remembered. The health care program can be manually or

electronically recorded. A guide detailing the management of the health and social care staff is

provided in the NHS Code for Practice Care 2006. This policy is funded by the NHS.

Demographic information on the individual who takes care of the care environment is an

internal requirement. Documents on paper or electronic documents are required in compliance

with internal and external documentation requirements. E-document forms include

identification of care plans, medicines, and food and review drug records. Documentation

requirements should be achieved with the help of various tools and opportunities in a care

setting. Any medical diagnosis documentation used in a care setting include table notes, patient

records, medications and medical letters, etc. Internally, correspondence, clinical forms and

lists of drugs also play a significant role in compliance with criteria for documentation (Cornock,

2019). Fulfilling the legal and administrative requirements are additional identification

requirements. The Act 2005 regulates and guarantees that health care entities keep records

confidential. There is a record keeper to be accountable to Parliament, and documents must be

maintained by healthcare organizations. Both healthcare practitioners have a duty and

obligation to comply with the liability when producing and using patient records and

information and services. Therefore, in an effort to preserve medical records, a treatment

environment must meet lawful requirements. The patient will face death in the specified
scenario due to an absence of record storage or use. Internally and externally, manual and

electronic documentation are expected to be processed so patients are able to receive proper

medical care (Gibson & Lillie, 2019). To comply with the requirements it is necessary to

maintain a manual record in a secure locker or to keep electronic records with safety

procedures. In order to ensure the protection of the record, it is necessary by law or regulation.

However, the recording of various issues relevant to record keeping is an internal responsibility.

Various recording issues can relate to the storage and sharing of information. In case of doubt,

the person concerned must be identified so that he or she can provide support or advice (Cree,

2019).

Current Process Related to Storing and Sharing Records

There are several reasons to keep medical records, but above all two are outstanding:

 To create a complete record of the patient's journey through services

 To allow continuity of care both within and between services for the patient and the

client.

We have to be transparent, precise, truthful and timely about the reports in healthcare (that they

should be published so near the time they occur). Specific record keeping methods are used in

healthcare environments. Many organizations use handwritten notes, others switch to computer-

based systems. You would have to be able to comply with any record keeping standards, hand

written or electronic, set by your employer. This means that you must:

 Know how to use your organizational information systems and software

  Protect any passwords or Smartcards you are issued to allow access to systems and do

not share them with anyone.

 Make it easier for illegal individuals to see written papers in public areas not to be left

and for any computer device to be safe before signing up.

In this section we will look at the principles of record-keeping, including the need to maintain

confidentiality between patients and clients. The RCN provided guidance on the record keeping

and counter-signing known as delegating papers. Nonetheless, we have to be cautious before

beginning to address these concepts, apart from being straightforward, reliable, truthful and

timely about what we write. That is, we must ensure that we do not write or understand anything

as follows:

 Prejudiced

 Insulting or abusive

 Racist, sexist, ageist or discriminatory in any way.

Making Recommendations for Improvement

The computer-based records of patients and systems they run are important technology in the

health sector, partially because the difficulties faced by health professionals in relation to

knowledge management are that every day (Harding, 2020). Technological advancement

enables absolute cost-effective access to full; reliable patient information for CPRs and CPR

systems and offers improved efficiency and enhanced features that can be implemented to

overcome the challenges of the information management system. The CPR will play an
significant role in improving the quality of patient care and enhancing the clinical theoretical

foundation and also in reducing and moderating healthcare costs. The Study Committee of the

Institute of Medicine (IOM) claims that a new effort has the right time to make CPRs a

mainstream medical technology in the space of a decade. In ten years' time, it will be necessary

to achieve this goal nationally and work hard. In many important areas more research and

improvement are required to ensure that services meet the needs of patients, physicians, staff,

non-profit payers, researchers and policymakers (Mitchell, 2019). To order to protect patient

privacy, for example, timely access to information on various sites needs to be balanced.

Systems must have both tremendous user versatility and the data transmission and sharing

requirements necessary. Implementation of CPR would entail improvements in organization

and behavior. Organizationally, the many components of the pluralistic UK health care system

would need significant coordination. It will allow users in the actions of CPR systems to learn

new ability to use and modify their documentation behavior.

Technology Used in Recording and Reporting

Patient record computerization is moderately growing and the trend will likely continue,

particularly with improving the technology and making it more accessible and increasing

demand for knowledge about healthcare. However, if potential medical records are just digital

copies of most current records an opportunity to improve a vital tool for healthcare has been

lost. The committee, for example, aims to include easy access in the medical report of the

future to a list of current concerns, a clinical rationale map, and a health record of the medical

and latest details about the different care options to address the patient's condition.

Automation of patient records may provide quick access and sound management of data
elements, but the quality of data elements depends on how the practitioners actually collect

and archive the data. In addition, modern apps that are not associated with conventional

patient records would require access to bibliographic and information repositories. Therefore it

is, but not appropriate, necessary to automate patient record recovery, repair, and use to

enhance records. The Committee believes that the patients' record can, must and will develop

to meet the increasing health-care needs given existing and emerging computer technologies.

The chapter outlines the features of potential patient records that will fulfill these needs, and

examines others extensively to underline the nature and complexity of the problems to be dealt

with (Vinic, 2019).

Advantages of Technology Used in Recording and Reporting

Technology is used for documentation and monitoring, and the opportunity to electronically

share health information can help to provide patients with better quality and protection while

allowing significant changes to their organization. Technology is used in the monitoring and

documentation of patient care services, and improved treatment is delivered by:

 Provide reliable, current and detailed patient information at care level.

 Enables easy, more coordinated, secure patient records access to

 Written information safely exchanged with patients and other professionals.

 Help providers treat patients more accurately, reduce medical errors and provide more

efficient treatment (Gauri, 2019).

 Increased contact and coordination with patients and staff, as well as convenience for

healthcare.
 To make the prescription safer and more reliable.

 Help to promote accurate, accurate coding and billing in a more readable way.

 Improvement of patient data privacy and protection.

 Providers of support improve efficiency and integration between work and life.

 Allowing suppliers to achieve their business goals by rising production.

 Reducing costs by reducing compliance, enhancing protection, reducing test replications

and improving health.

Benefits of Involving Service Users in Record Keeping Processes

Benefits

Democratic principles

 Only consumers should accept the option of priority and rationed services in health

(such as the NHS):

Participatory democracy

Public accountability

Transparency

 User engagement acknowledges the self-determination potential of citizens and allows

them a say in managing their treatment. The Alma Ata WHO Statement notes that

"people have a right and a responsibility to take part in the preparation and

implementation of their health care, individually and collectively" (WHO, 1978);

 Implicating consumers in the preparation of programs enhances their understanding

engagement and helps to affect their concerns.  

 Service improvement

 Engagement with consumers will enhance the efficiency of activities in public health. For

example, long-term patients may have experiences that healthcare providers and

politicians lack in their treatment (Taylor, 2019)

 Patients and caregivers cannot face the same interest conflicts as physicians and

politicians who may have financial interest in healthcare.

 The development of public-technical expert relations.

 Participation of service users theoretically implies the provision and improvement of

health services, enhanced quality and clinical benefit of research studies and expanded

utilization of the tests.

Policies to Keep and Maintain Records

Policy Statement

The Trust trusts that the Health & Social Care Documents include information to be accurately

documented, updated on a regular basis, concise, accurate and readily available.

Such principles promote the safe diagnosis and medical treatment of patients with the inclusion

of data on clinical results, decision-making, prescription medication, evaluation, treatment and

knowledge Higher-grade documents provide accurate clinical evaluations, encourage continuity

of care and risk identification and allow early detection of the problems involved (Watson,

2019).
 Record Keeping Policies

The record keeping policy, including data security and access to information, will extend to all

care facilities. The strategy will explain its main record keeping principles and how it complies

with existing regulations. Providers of treatment should have clear policies and procedures on

all documents available and maintaining documents. To ensure they comply with all

specifications, they will use the following checklist.

 To create, use, track, and analyze specific protocols for all personal records such as

needs evaluations, risk assessments, treatment plans, medical reports and reviews.

 Make sure that the records are suitable, correct, up to date and clearly structured for

any person who uses the service.

 Instruct the staff to ensure that record entries are held up-to-date and correct as soon

as possible (Women, 2019).

 Instruct staff to document written correspondence on the correct personal record

about a person's diagnosis, care and assistance as soon as possible.

 Regularly check the documents are transparent, truthful and reliable and protect their

integrity and confidentiality for the people who are using the service.

 Have a secure record storage device.

 Consistent protocols to allow people to access all documents, both inside and outside

the facility, when necessary, in accordance with the relevant legislation.

 Have specific protocols for safe knowledge sharing with all external practitioners,

agencies or organizations which will, in general, obey the principles of 'need to learn.'
Although the criteria are different from one another in successive regulations and standards

guidelines, they are not a significant change in the regulatory framework towards fairly

constant recordkeeping requirements. Confirmation of good record records on mental illness

decision-making, as well as in relation to the demands for directors of fit persons, may alter

particular criteria.

Confidentiality Policies

Confidentiality procedures can also be clarified in order that readers can appreciate the

importance of certain activities and practices by offering an overarching approach to managing

access and confidentiality of information concerning company risk management. Organizations

may have many important datasets: patient records, financial reports, marketing plans,

monitoring of employees, study findings, etc. Such data sets can be regarded as business acquis

and can lead to financial disadvantage or loss for the corporation being revealed (Howie et al.,

2019). Whilst health data are qualitatively distinct from private corporate information and have

some risks and obligations to protect patient information, confidentiality policies are most

effective in recognizing specific health data problems and ensuring sufficient protection (Howie,

2019). Maintaining knowledge available for care, if appropriate, is potentially safer than

restrictive methods, for physicians within the department by virtue of the policies. The

Committee members have defined alternative approaches, which may not be standardized or

flexible, but which more restrictively limit access to health information. Some organizations

allow open access for all staff and doctors to all patient files, but restrict the access to their

registered patients through referring doctors. This approach only rarely causes an organization

to restrict access to a doctoral program, but does not minimize the vast number of physicians
who receive and treat patients on a regular basis. Many organizations grant doctors

unrestricted access to their current patient records, but only when valid and recorded

conditions exist, access to other data (Mwila et al., 2019). Here, the caregiver may type the

access reason or pick the reason from the list. Common reasons are provided along with the

blank fill-in option, such as the "primary-staff consultation available" or the "emergency

service." A notice of access can be automatically forwarded for examination to the primary care

physician. Failure to connect is prevented if app users are aware that their activity is tracked

and monitored and penalties can be exercised for violations of patient privacy. Without

burdensome or time consuming action, the system blends the need for restricted rights and

emergency or inevitable access needs (Taylor, 2019).

Policies to Protect Sensitive Information

Many health institutions have procedures which provide clear security for information on

confidentiality, such as mental health records, HIV status records, pharmaceutical items, drugs

and alcohol, celebrity health records, etc. State or federal legislation governs the protection of

these information and individual individuals provide a safeguard on a voluntary basis. And there

was classified information in other areas reached by the committee members.

"E-mail access notification" is an audit trail system functionality that records data access.

Policies Guiding Release of Information

Identifies the requirements to access health information and who is the first move to ensure

that non-authorized disclosure does not compromise the privacy of patients. Common

elements of policy on disclosure of health information include:

  Who needs information to be released

 Who has authority to obtain information and who is authorized

 The form and depth of the information to be made available

 Additional patient consent circumstances are required

Organizations that track patient information by keeping in the permanent health record a

signed authorization form (where necessary), records of information which has been released,

the date the information has been released and the person releasing the data and the

individual signing the employee's signature. This record offers an audit trail if accidental

disclosure is suspected (Ashurst, 2019).

Conclusion

It is crucial to maintain proper records when caring for a patient in order to facilitate the

treatment of patients and enhance communication. Effective record keeping is a vital tool to

establish good healthcare and to improve integrity in nursing services and a strong teamwork.
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