Effective Reporting and Record-keeping in Health

  • 20 Pages
  • Published On: 20-12-2023

This assessment has two main parts in it where the one part is about the legal and other regulatory determinants of reporting about the details of the care homes and the record keeping systems of any healthcare settings. This assessment will explore all the aspects of the external and internal record keeping system and the needed requirements for that in a healthcare setting. There is an in-depth knowledge about the statutory and regulatory inspection bodies & governing bodies in relation with the healthcare setting. There is also an evaluation presented where the working arrangements for a proper record keeping, storing and on-time sharing of the necessary information for improvements. In the second part the appropriate technology and its optimal use in case of care settings are illuminated with which type of instruments are needed is also given. The briefing of how the technology can help in record keeping and reporting in the care systems are presented with the pros & cons of those technologies below. The technologies how provide the safety & security of the patients’ personal confidential information keeping in analysed and the proper way to ensure the confidentiality is given so that it can be learned by the managers or supervisors of care settings. Adding to these, this assessment will produce core knowledge about the legible, accurate, coherent & concise local and national guidelines & policies of reporting & record keeping techniques in different types of healthcare settings for servicing the users of those care setting places.

Part 1: PLAD Portfolio

LO1: Describing the legal and regulatory aspects of reporting and record keeping in a care setting

P1: Describing the statutory requirements for reporting and record keeping in health care setting

The healthcare record keeping system is that setup where the detailed information about all the patients, about their health conditions, their medical treatments going on, and the past and present medical history is kept. This information are said to be as confidential as any other type of legal information can be considered (biomedcentral.com, 2017). All these patients’ health records are only flashed to either the doctors or care givers of that patients or to the family members of that patients when giving discharge from the care giving place. There are certain requirements that are statutorily important and necessary to keep a proper reporting and recording of the details under the Regulation 20 (1a) & (1b) of the Health and Social Care Act 2008 whose activities are later regulated in 2010 (biomedcentral.com, 2017).


The care givers must attain that the treatment and care records are separated of each of the patient

These records are utilised to plan further treatment line according to the needs of the patients

The records that are noted must be updated regularly to have an up-to-date knowledge

The records must be accurate, prompted and clearly factualised

The record keeping system must assure the confidentiality, dignity and resecting the personal space of that patient without using any judgemental or libellous comment about the patient

All these are must to maintain and follow for a good and proper record keeping system.

P2: Describing the regulatory and inspection bodies required for reporting and record keeping in a health care setting

Regulatory bodies of the health care settings are those bodies that are comprised of the local and national government entitles who are majorly responsible for regulating, forming and then enforcing the rules and laws that are basic and required to protect the safety of the patients’ personal care details according to the standard quality of the general medical care (biomedcentral.com, 2019). The primary inspection & regulatory bodies are enlisted as –

Medicines and Healthcare Products Regulatory Agency (MHRA) who are a government agency, responsible for ensuring that whether the medical tools and devices and the medicines are safety accepted and must be in proper working condition in the healthcare settings.

General Medical Council (GMC) who is mainly responsible only for the appropriate regulation of all the doctors working in the caring fields.

Nursing and Midwifery Council (NMC), likewise GMC looks after the nurses and other staff members who takes care of the patients and the midwives who cares the patients.

General Optical Council (GOC) regulates the functions of the dispensing opticians, optometrists, junior interns and students of the optician fields and other optical businesses.

Health and Care Professions Council (HCPC) who regulated under them the 15 different types of healthcare professional arenas including therapists, podiatrists/ chiropodists, clinical scientists, biomedical scientists, dieticians, occupational therapists, hearing aid dispensers, orthoptists, operating department practitioners, practitioner psychologists, physiotherapists, prosthetists / orthotists, language & speech therapists and radiographers.

Charlesworth and Johnson (2018) advised that all these inspection and governing bodies are aimed at protecting the health, social care and wellbeing of public under the regulation of Professional Standards Authority (PSA) which was previously named as the Council for Healthcare Regulatory Excellence).

M1: Analysis of the implications of non-compliance with legislation, regulating and inspecting bodies’ requirements

The failure in the compliance of the regulations, legislations and inspections through the governing bodies and their requirements within the healthcare are the safety rules and duties or any other kind of electrical safety duties and measures that results in the exposure of a person towards death or risk of having death, any illness or any such kind of serious injury. The non-compliance of these legislations, regulating and inspecting bodies’ requirements often result to the prosecution in front of the local or national Magistrates Court (frontiersin.org, 2019). The regulatory compliances in the healthcare settings are some rules that are adhered with the laws, guidelines and specifications set by the healthcare governing government entities which are relevant with the protection and safety within the care giving service arena. Non- compliance is the disagreement, disobey or violation of those compliant laws, specifications and rules which often brings the result of penalty or punishment under the federal fines.

The challenges which comes due to the non-compliance of these regulatory, legislative and inspecting body laws and rules can be massive sometimes resulting into huge disasters regarding the patients and their healthcare issues and complications (Hetrick et al. 2017). These challenges can be from the financial side in care setting also because the non-compliances also affect the financial front on that area. Financial challenges can be like lack of proper treatment instruments and testing devices could be there or the day-to-day expenses can get affected or such type of challenges hampers the normal running of the healthcare settings.

D1: Evaluation of the consequences of non-compliance with reference to the media, service user safety and the credibility of the care setting

The breaching of laws and regulations in the healthcare and social care settings is a major criminal offense since it is directly related with the safety and security of lives of many people. So it becomes mandatory that all the regulations must be fulfilled or if non-compliance occurs then these kinds of consequences have to face –

Financial punishments and penalties – The housing and social care setting governing and inspection bodies if finds out the non-compliance of the defined laws, then they can issue legal notices or can feed up with charges of breaching the specified rules and legislations and can also prohibit from the service providing (Li et al. 2021).

Reputation damage – Reputation is one of the major things that work in case of care providing homes since reputation of the place is directly related attraction of care users. It is the responsibility of employees that when the healthcare and safety breaching incidents happens then it must be recorded and taken to the governing entities so that it can be prosecuted and brought forward by the Health & Safety Executives in UK where most of the cases it has been seen that the conviction rate of success becomes high nearly about 94 per cent (Liabo et al. 2017).

Putting lives into danger – Non-compliance can have huge effect on the health care and safety regulations since it can put the lives of many people in danger by not following the rules and specifications set up by the inspection and legislative bodies.

Many reports and surveys says that non-compliance is clearly an issue of the negligence and ignorance in following the set rules for the safety and benefit of the patients and their lives whose breach might bring out massive negative results sometimes

LO2: Describe the legal and regulatory aspects of reporting and record keeping in a care setting

P3: Describing the process of storing of records in health care setting

In past times the record keeping was a huge responsibility and an issue since at that time there was hand written system was followed but now the scenario has changed totally upside down and as the involvement of computer-based record keeping has been initiated in the care settings (Luchenski et al. 2018). It has made the reporting and record keeping process more convenient from previous times. There is a specific system for keeping records properly.

First all the detailed information of any single patent is collected and stored up in the files in series.

The storing must be done form the old to new records so that whenever the latest records are needed, t can be found easily.

The records must be separated according to the traditional records, new treatment records, operative notes from the doctors, progress report and many such things.

The records must be prepared into two sections where one section will be given to the family members at the time of discharge and the other section is kept within the care setting as details of that patient for further use or as examples to train the interns also these records are used (ncbi.nlm.nih.gov, 2017).

P4: Explaining the reasons for sharing information within a healthcare setting and external bodies

There is a long list of reasons for which the sharing of the internal patients’ information with the external bodies and executive is said to beneficial for the patients’ good health and well-being. This kind of sharing are only provided with the government and other legal healthcare data collection bodies so that when the national data are collected and stored these information can also be added in them for evaluation and analysis (ncbi.nlm.nih.gov, 2020).

The sharing of the data of patients helps in improving the efficiency and care of the care taking process but it requires an appropriate approach towards carefulness.

It is a good habit to share information since it reduces the pressure of urgent care services which is a very much tangible benefits of the sharing of data.

The most prominent reason is that the simple sharing of patients’ data is essential to provide the best possible care to the patients.

The two main elements of the NHS care delivering plan – the front door clinical care system and the effective accountable care system where both are dependable o this sharing system (ncbi.nlm.nih.gov, 2017).

These reasons are few apart from a remaining lost list in regards with the information sharing aspect with the external bodies.

P5: Illustrating the internal and external requirements for recording information in a health care setting

Both the internal and external record keeping of the patient data is mandatory to note down on the electronic and hand written paper documents. These types of noting are done of the medications, care plans, nutrition diet and documents of the prescribed tests and the results of these tests. The external record keeping is to fill the requirements of the legal and regulatory needs from the Public Records Act 2005 that governs and makes sure that health care settings are keeping the records safely or not (Nyathi et al. 2018).

The new staffs when starts working in any care settings must have to know about all the materialistic details in compliance with the health care and social care in care providing settings. The internal record keeping is useful for consulting with doctors of that care setting and with external speciality doctors also (sciencedirect.com, 2020).

When all the patients’ records are kept safe then these can be examples for other cases where same issues or treatments are going on and the doctors can take advice from the previous records that what happened in the past and what can happen in future.

M2: Examining the current processes in health care setting related to storing and sharing records

Apart from the old, time-taking & hard working hand written record keeping system, the new system is technology based and clear & sorted. The current of record keeping process is much accurate, clear and much more effective in supporting the clinical decision making process and patient care (sciencedirect.com, 2020). There are certain differences in the current record keeping process rather than the old times:

The current procedure is legible and clear when the notes and patient details are written taking extra care so that other people can read it and find it simple to convey.

The new technology based process made it easier and less time taking to enter the records with the best possible accuracy and if any mistake happens then it is automatically corrected through the latest technology.

The current system is tampering proof because in the latest technology based system i.e. computerised system doesn’t allow tampering with the records if they were secured with password protected system

The checking system in the current process is almost without errors and faults or even if there comes out any mistake then it could be corrected in no time.

All these latest and current technology based systems have made the record keeping system much easier and convenient than before.

D2: Evaluating the healthcare working setting’s arrangements and processes for storing and sharing information, making recommendations for improvement

The proper arrangement of a well-equipped and well organised healthcare setting needs some of the following sharing, storing and recommending improvements that can make any healthcare setting better in their functioning and will also be able to give the best standard care services which every patient desired and pursues the rights to get from the responsible personnel. The healthcare setting’s appropriate arrangements include:

Charlesworth and Johnson (2018) advised that proper tracking of the incoming and outgoing of the medicines, injections, bandages and other essentials which are must too be present in care settings.

For keeping the records in electronic devices, proper setups are required with appropriate software that can make the working easier.

The statistical file maintenance is also a must required thing in every care setting since an unorganised and unarranged file and record maintenance will create more difficulty in getting the desired information whenever needed instantly (Suso-Ribera et al. 2018).

Latest pathological equipment, operating devices, diagnostic machines and many more such things are must to be availed in every cares setting for giving good services to the patients coming there for treatment.

Part 2: Report

LO3: Review the use of technology in reporting and recording service user care in a care setting

P6: Describing that how technology is used in recording and reporting in health care setting

Technology nowadays in involved in every systematic work but in case of healthcare systems, it has been a blessing for all the procedures whether in the treatment fields or in the record keeping functions. Specifically in the healthcare setting, technology is used in:

The Tele-health monitoring applications for the home based management of the health care.

The entire web based community health care services for the patients and for their families too.

Suomi and Damalie (2020) stated that the latest system of the Personal health recording applications where the patients creates and stores all their personal health information details which can be later used for their treatment and doctor consultations.

The passive monitoring and record management system which includes the implementation of training and operations used by the end users.

The robotics applications and treatment techniques are the latest development which is much beneficial for treating the patients with less operational activities (springer.com, 2017).

Another technology based system is the motion sensor health care applications which is helpful in care setting and also in home care management where huge infrastructures cannot installed, there these technologies fills the gap (biomedcentral.com, 2019).

All these systems and the technology based application platforms have made the support of record keeping and reporting system much easier for the care settings as well as for home care setting also. These technological applications helped in quick diagnosing of both acute and chronic diseases that were much time taking and high cost previously but now the current procedures are cost effective and less time taking than past time (Sikka et al. 2019).

P7: Explanation of the benefits of involving service users in record keeping processes

The service user involvement can be defined as the most primary and basic active participating of any person having a lived experience and knowledge of any kind of mental stress or distress and shaping their all the personal health based plans depending on the knowledge of how and what can work best for their betterment (Surr et al. 2017). A lot of number of researches and studies have focused an d highlighted the facts that there are a long list of benefits of the user involvement in the process of record keeping procedures in the healthcare settings. The benefits of involving the user services have always given credited in order to improve the accessibility of the services whenever required and the information at the time of quick accessing (Suso-Ribera et al. 2018). There other types of improvements have also been found in the user service involvement can be enlisted as development in the coordination while giving care and treatment in the care settings and also in the record keeping and reporting activities where all these are important to have a better open and clear communicative relationship between the clinicians, patients and their families and the doctors who are treating the patients for receiving the accurate and correct required treatment (Yu et al. 2021).

M3: Reviewing the use of digital technology in relation to healthcare medical management procedures or in care plans

Digital technology in context with healthcare system can be defined as the high end and latest technology-enabled care (TEC) system where the involvement of the convergence of all types of healthcare technology, digital media services and mobile devices are used in the process of the medical management process (Suso-Ribera et al. 2019). The digital technology enables the care givers, patients and the healthcare professional (HCPs) to get the access of all the necessary data and information much more easily than before and also adding to that it contributes in improving the quality and the desired outcomes from both the expected social and health care in care homes (biomedcentral.com, 2017).

The most common uses of the digital technology in care giving and record keeping system includes searching of the medical information and factual resources, encouraging the facilities of the clinical support system, keeping accurate monitoring of the good quality care given to people, mapping of the treatment process starting from the initial stages to the final stages of the diseases and betterment process and also monitors the speed of spreading of the viruses and infectious diseases with the well-equipped tracking of the medicinal, drugs and vaccines supplies for the care homes (biomedcentral.com, 2019).

The usage if the digital and technological instruments and tools have wide range of capacity to potentially improve the management abilities of the care settings to give an accurate diagnose and better effective treatment of the disease and keeping proper records of those diagnostic procedures (Yu et al. 2021). The involvement of digital technology in care system management from the view point of a manager of a care home enhances the proper delivery of individual as well as community health care facilities (frontiersin.org, 2019). The digital tools can be like the computing platforms, medical software, connectivity tools, sensor instruments and the other related useful measures.

D3: Evaluating the effectiveness of the use of technology in terms of meeting service user needs, ensuring appropriate care is given and maintaining confidentiality

The use of digital technology in the healthcare system in terms of meeting the user service needs for ensuring a proper care is given or not and also maintains the confidentiality in case of record keeping and reporting. In order to make a digital health care system, the primary effectiveness initiates with the addressing of all the key components including the infrastructural and treatment setups of the care centres (Li et al. 2021). While the technology is developing quickly and moving forward simultaneously it is true that the clinical practices, producing the evidences of accurate treatment and deploying appropriate applications and services for a better future of the healthcare system and giving people equal service receiving opportunities too. In the scenario where there is needed the perfect maintain of the confidentiality of the patients’ personal and medical details, in that case also the digitalisation of the services and high tech instruments are effective in producing the desired results (ncbi.nlm.nih.gov, 2017).

From the part of a manager of any care setting, the necessity is increasing of the advanced care units, frameworks and digital technologies such as biometric identification systems which are trust worthy is aspect of security and safety of the personal details of people (Hetrick et al. 2017). In ensuring the required care plan and exact treatment to all the individual patients in a care setting is also can maintained by only the effective digital technology usage in health care settings.

LO4: Demonstrate how to keep and maintain records in own care setting in line with national and local policies

P8: Presenting the accurate, legible, concise and coherent records regarding service user care or different service users following in the healthcare setting’s guidelines

In order to maintain a legible, coherent, concise and accurate record keeping system and user service care management in different types of healthcare settings along with following the guidelines of the local and national policies have two main consistent considerations in it (ncbi.nlm.nih.gov, 2017). In this regard, the ethical consideration of the confidentiality maintaining, the application of the national and local policies helps to become legal, ethical and moral with the empowering of the digitalisation of the care centres (ncbi.nlm.nih.gov, 2020). The digital record keeping system is mostly used in maintaining the requirements of the reporting services and maintaining the confidentiality in it. In case of a care centre or care home, the manager must attain the requirement of the briefing of the demanded details about the patients under keeping the activities under the guidelines after that the Care Quality Commission (CQC) report can be presented (ncbi.nlm.nih.gov, 2017). Not only the manager but all the other staffs are also responsible of keeping perfect patient records by all the staffs.

The accuracy is dependable on the correct usage of the digital technology system in case of the record keeping actions might take place. Inaccuracy in the information that is recorded might result in wrong treatment or having wrong information about the medical history to be released from the care homes to the patients for further usage in medication can go wrong (springer.com, 2017). Different types of healthcare settings have different types of management system in reporting about the patient details and using the digital technology in record keeping is also varied from each settings. For implementing a concise and clear record system appropriate techniques and ways must be used safeguarding the confidential details about the medical past history and the present on going treatment line of procedure.

P9: Explaining all the different aspects of health management of service user records with reference to compliance with national and local policies and guidelines

Basically the guidelines in compliance with the national and local policies are those rules which are defined as an accurate and systematic preparation of the statements for helping in the assisting to the practitioners and their patients to take important decisions about any such appropriate healthcare in certain specific circumstances (Nyathi et al. 2018). Guidelines can be said as the tools to facilitate the decision makers who are working for the betterment of the healthcare related matters the power to make a better future in this regard. It is coherently necessary to follow the local and national both guidelines for all the care homes to be under legal standards (Sikka et al. 2019).

There are certain laws and acts that are followed as the standard guidelines for maintaining the proper quality of healthcare services and matching the guidelines are the Health and Social Care Act 2012 and the Equality Act 2010, where both works in different aspects in maintaining the rules of healthcare centres (Suso-Ribera et al. 2018). The Equality Act 2010 looks whether there is followed the equality rules or not without any biasness to all the patients seeing the care homes. And the Health and Social Care Act 2012 was introduced to formulate the legal duties of the care centres, rights of the patients and the obligations implied on both the sides which are must to follow to keep within the lines (Hetrick et al. 2017). All the digital compliances also come under the guidelines of these acts and laws within the local and national borderline guidelines in reference to the service user records and reports.

M4: Analysis of the process of maintaining records in own setting, identifying any potential or actual difficulties

Various analysis reports and researches showed results that there are certain dimensions of the difficulties and challenges that comes while following the marinating of patient records and care setting and further reporting them to the higher superiors and doctors whenever demanded by them are the logistic problems, the ethical issues, the accessibility and physical challenges and finally preparing the solicited data documents (Liabo et al. 2017). Problems that generally arise are mainly difficulty in keeping the track of incoming and outgoing of the inventory i.e. the medicines, injections, and other equipment that are used in the care centres. Further adding to this, another potential problem that is seen is inability to furnish quick actionable reports i.e. the reports that are maintained are long and lengthy with briefs about the detailed treatment line but a quick response needs a short, simple, clear and consisted record that can give a conception with is enough to instantly understand the case details and react according towards the further treatment of that patient (Luchenski et al. 2018).

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The actual difficulties which are suggested by the nurses, care givers, staff members and other members of the healthcare setting including the doctors are no facilitating of the electronic record keeping system in every corner of the region (Surr et al. 2017). Here are still so many care settings which are under developed and unnoticed for developments and lacks proper filing of the statistics of all the patients’ medical details (biomedcentral.com, 2019). Rather than these were registered in hand written registers and paper files that are documented in files. The real and actual scenarios have revealed that there is a huge insufficiency in proper technologies in case of treatment functions and inefficient disposition of the detailed patient records with no proper managing system for electronic record keeping system in actual scenes as said by the doctors, nurses and staff members (ncbi.nlm.nih.gov, 2017).

D4: Evaluating the effectiveness of own completion of documentation in terms of meeting service user needs, ensuring appropriate care is given and effective reporting is carried out

While evaluating the completion of the documentation which must ensure the proper and appropriate reporting system in the care settings there are certain aspects and points that are noted here classified into different dimension and experiences by the nurses, doctors, and other staff members.



The above assessment highlighted that different types of healthcare settings have different types of management system in reporting about the patient details and using the digital technology in record keeping is also varied from each settings. The guidelines in compliance with the national and local policies are those rules which are defined as an accurate and systematic preparation of the statements for helping in the assisting to the practitioners and their patients to take important decisions about any such appropriate healthcare in certain specific circumstances. The technology based application platforms have made the support of record keeping and reporting system much easier for the care settings as well as for home care setting also. These technological applications helped in quick diagnosing of both acute and chronic diseases that were much time taking and high cost previously but now the current procedures are cost effective and less time taking than past time. Previously the record keeping was a huge responsibility and an issue since at that time there was hand written system was followed but now the scenario has changed totally upside down and as the involvement of computer-based record keeping has been initiated in the care settings. Internal and external both the record keeping of the patient data is mandatory to note down on the electronic and hand written paper documents. These types of noting are done of the medications, care plans, nutrition diet and documents of the prescribed tests and the results of these tests.


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