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. This is to the advantage of service customers in a variety of respects.
For example, good documentation will explain the needs of the clinicians and service users, and
misunderstandings and mistakes will be less likely. Good equipment would ensure that
maintenance recorder and service users know they maintain their devices and equipment in an
appropriate way and thus are less likely to break up and jeopardize their health.

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:

 They maintain a record of every service user's care and treatment.

 The records are used to prepare and explain the person's care and treatment according
to his needs.
  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 records provide information on the patient in relation to his or her background, care
and treatment from other professions and agencies in a confidential manner.

 They record all information about care and treatment of service users, including word of
mouth information, eg telephone calls.

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.

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
Regulation 20 of the Health and Social Care Act 2008 (Regulated Activities) 2010 sets down the
legal standards for record-keeping. 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. 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 a "acceptable" time, a record
should then be kept and securely destroyed. The Regulation provides the basis for a record-
keeping program that allows care providers, as set out in Regulation 20, to be legally-compliant
and to pay attention to all the relevant aspects. 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. 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. 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 connection with this situation, the new workers need to learn the information on health and
social care conformity. In order to recognize the criteria of internal and external care
registration, it is best to review the law and protocols. When the patient died in the care
environment, the local hospital declined to share the patient's health record with the family
member. The family member had the patient's legal rights, but the failure to provide
documents indicates that the case will not comply with the rule. The following section
therefore includes the criteria for internal and external healthcare reporting (Adegboyega &
Musa, 2019). It is vital to know a person about every aspect of his or her health, including his or
her mental and physical well-being. The record must be held in such a way that a patient may
be remembered. The care environment can be electronically or manually registered. The 2006
NHS Code of Practice Record Keeping provides a guideline that makes sure that health and
social care staff are able to document their treatment. The NHS is qualified to enforce this
strategy. In a care environment, demographic information on the individual taking care is an
internal necessity. Internal and external documentation standards require the documentation
of information on paper or electronic records. E-document forms include registration of
treatment plans, medications, diet and records to be used in check prescriptions. With the
guidance of many resources and options available in a care environment, documentation
criteria can be met. Table notes, patient history, prescriptions and letters and medical reports,
for example, are some documents of medical treatment used in a care environment. 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.

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). In healthcare environments, various record-
keeping techniques are used. Many places of work use hand-written documents, others have
switched 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 issued guidance on record keeping known
as delegating records and countersigning. However, before we start to discuss these concepts, we
need to be mindful that we have to be vigilant, apart from being direct, precise, truthful and
timely about what we write. That means that we will make sure that nothing we write is or can be
interpreted as:

 Insulting or abusive

 Prejudiced

 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. 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. CPR can play an significant role in
improving the quality of patient care and in reinforcing the theoretical base of clinical practice,
and can also lead to health care costs control and moderation. 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. 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 a 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.

Advantages of technology is 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.
 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
 In deciding priority and rationed health services (such as the NHS), even users should
encourage:
-  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.
 Patients and providers may not face the same conflicts of interest as physicians and
policy-makers who may have a financial interest in healthcare services.
 The creation of a public-technical relationship with experts.
 Involving service users potentially means making health care more available and
appropriate, enhancing the efficiency and clinical value of health studies and increasing
results use.

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.
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.
 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 policies explain the overall approach to managing access to and confidentiality
of information on the organizations 'risk management can also be presented so that readers
can appreciate the value of such activities and practices. Organizations also have multiple
sensitive datasets: patient records, financial details, business plans, employee reports, research
results and so on. Each of these data sets may be viewed as business assets and their disclosure
may cause the company financial disadvantage or loss (Howie et al., 2019). While this may offer
strong motivation to protect health information, health data is qualitatively different from
corporate proprietary information and carries specific risks and responsibilities, confidentiality
policies are most successful if they identify particular health information issues and provide
sufficient security. As a matter of policy, most service organizations provide doctors with access
to all medical data within the agency; ensuring information is accessible for treatment if
appropriate and is theoretically easier than restrictive approaches. Members of the Committee
have identified alternate methods that, while maybe not universal or scalable, limit access to
health information more restrictively. Some organizations require unlimited access to all
patient files for all staff and physicians, but limit the access rights of referring doctors to their
registered patients. This method allows an entity to limit the access to a program for doctors
only rarely, but also does not restrict the vast number of doctors’ routinely receiving or seeing
patients. Many organizations give doctors unlimited access to their current patients 'records,
but allow access to certain data only when clear and recorded requirements occur (Mwila et al.,
2019). In these instances, the caregiver may type in the reason for access or to choose the
reason from the list. Common motivations such as "primary care provider consultation
required" or the "emergency service" are given on the screen, along with a blank fill-in option.
An access notice can be forwarded to the primary care physician automatically for review.
Inadequate access is avoided if device users know their activities are registered and checked
and penalties for infringements of patient privacy can be enforced. This program combines the
need for restricted rights with emergency or unforeseen access needs without burdensome or
time-consuming actions.
Policies to Protect Sensitive Information
Many institutions in health care have procedures that have specific protections for confidential
details, such as records in mental well-being, HIV status, medication, drugs and alcohol, health
records of celebrities and other commonly known individuals. The protection of such
information is regulated by state or federal law; individual entities voluntarily provide certain
protection. And other places accessed by members of the committee held confidential details
apart.

"Access Notification e-mail" is just an audit trail system feature that documents information
access data.

Policies Guiding Release of Information

Identifying the circumstances under which information on health can be made accessible and
who is the first step to ensuring that unauthorized disclosure does not breach patient privacy.
Popular elements of health information disclosure policies include:

 Who is required to reveal details

 Who is approved and entitled to receive information
 The knowledge type and scope that can be released
 The circumstances of further patient consent are necessary

Organizations that monitor patient information releases by holding a signed authorization form
(where necessary) in their permanent health record, records of what information was
published, the day the information was released and the individual who released the data and
the signature of the employee. This recording provides a trail of audit if unauthorized
divulgation is suspected.

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.