Table of Contents Introduction . 3 P1 Describe the statutory requirements for reporting and record-keeping in own care setting . 3 P2 Describe the regulatory and inspecting bodies’ requirements for reporting and record- keeping in a care setting . 5 M1 Analyse the implications of non-compliance with legislation, regulating and inspecting bodies’ requirements . 7 D1 Evaluate the consequences of non-compliance concerning the media, service user safety and the credibility of the care setting . 8 P3 Describe the process of storing of records in their own care setting . 9 P4 Explain the reasons for sharing information within its own setting and with external bodies . 10 P5 Accurately illustrates the internal and external requirements for recording information in own care setting . 11 M2 Examine the current processes in own care setting related to storing and sharing records . 11 D2 Evaluate own work setting’s arrangements and processes for storing and sharing information, making recommendations for improvement . 12 Conclusion . 13 References . 14 2 | P a g e
Introduction The health care processes a large amount of data, and so this information must be recorded and kept safe for reference. Effective reporting and record-keeping in health and social Care empower patients by putting them in control of their experience of their health. Record keeping in health also delivers integrated patient care breaking down geographical, professional, and institutional boundaries. Effective reporting and Recordkeeping are an essential activity to care service because it prevents patients from repeating the same information to many professionals which are found to be one of the greatest frustrations for service users. Over the years, effective reporting and record-keeping have ensured and improved patient safety by preventing gaps and mistakes in patient’s history record in terms of treatment. Record keeping in health and social care has caused a positive impact in treatment by enabling self-management care for patients that are recovering from an acute condition. Patients share their health information with their clinicians whenever they visit the health centre throughout their lives, therefore recording this information and using it to improve people’s health is useful to medicine. These recorded data from various health care institution and geographic locations present a significant advantage in innovative, efficient, and cost-effective research thus informs decisions in clinical medicine, health service planning and public health. Governments and other health agencies have legalised and prioritised the use of routinely recording health data as tools to improve patients care, transform health research, and improve health care efficiency (Coster C et al.,2006). This report illustrates legal and regulatory aspects in record keeping in health care, it further explains how technology has brought positive impact in record keeping. This report also demonstrates how record can be kept and maintain national and local policies. P1 Describe the statutory requirements for reporting and record-keeping in own care setting There are three legislation governing access to patient health record: The Data Protection Act 1998. The access to health records Act 1990, and the Medical reports Act 1998. The first governs the right of living individuals and authorised persons, the second governs access to deceased patients’ records, and the third governs the right for individuals to access reports relating to themselves provided by medical practitioners for employment or insurance 3 | P a g e
purposes. Access to this legislation is limited to protects patients’ records. Also, records can be limited to patients if it could cause harm to the patients mental or physical health. Parents have the right to access their children health records, but their confidentiality must be checked as well. (Dubovitskaya, Xu, Ryu, Schumacher, & Wang, 2017). Providing an accurate, timely, relevant clinical record that ensures the safety and coordinates care that involves the patient, carer and family are especially important in health care. Clinical and administrative staff contributing to a patient must provide an accurate health record which can be used to determine clinical decision making, improve patient care through clear communication of the assessment and treatment and care planning rational. There are several statutory requirements in reporting and record-keeping in my own specialist area in my own health and care setting. All information recorded must be up to date with every information their patient may share with them. This information must be kept safe and must be easy to access them for future use. (Archenaa & Anita, 2015). Health practitioners are accountable for ensuring that they are capable and aware of and knows how to use an information system, for example, using an electronic patient record system and medical devices in accordance. Written data must be readable, legible, and written in black ink to enable photocopying or scanning of documents; signed and be kept safe in a file if required. The records must be maintained and kept in a way that it can be transferred to other clinicians’ institutions in case of emergencies. There are situations whereby patients may lack their mental capacity to answer their own medical records and are not capable of making decisions at that moment. It is therefore essential to record any risks identified or problems that may have risen and that taken to rectify them if another episode occurs in the future. Care records have been introduced to enable sharing of essential information about a patient, such as medication, allergies, and adverse reactions. However, any required information of a patient must abide by the law by following the Data Protection Act 1998. (Wager, Lee, & Glaser, 2017). Every legal requirement and local policies concerning the confidentiality of health records must always be governed. Health records taken in a form media must be kept securely in lockable trolleys to avoid leaked information. Also, records must be continuously updated; this is important in terms of treatment. All recorded information must be timed, dated, and always signed. (Walton III, 2016). 4 | P a g e
