Effective Reporting and Record-keeping in Health and Social Care

Introduction

Record keeping and resorting are mandatory in the health and social care, where the health and social care professionals try to manage the patient data and personal information efficiently in the care home (Manogaran et al., 2017). The study aims at exploring the practice and strategy of good record keeping and reporting in the care home, in order to manage the patients and ensure confidentiality in the care home. Through this study, it is possible to identify he legal aspects and ethical guidelines of record keeping where the care home tries to maintain fairness and protect the data efficiently. In the second task of the study, it would be possible to explore the internal and external recording requirements in a care setting and review the use of technology in reporting and recording service user care. In the recent era of globalisation, there are various techniques to keep the record of the patients in the care home and utilize the personal information for delivering high quality health and social care services. The study mainly focuses on the record keeping strategy and Care Quality Commission or CQC standard of maintaining patient confidentiality where ABC care home is efficient to keep their patient record successfully. CQC have declared that ABC care home is efficient to manage their records. However, another care home beside ABC is not able to maintain their record keeping system and it further affects the fairness and patient confidentiality management in the care home. Another care home failed to maintain accurate records, incident reporting in line with RIDDOR or reporting of injuries, disease, and dangerous occurrence regulations 2013 and also it fails to keep records related to medical condition and treatment of the patients, fire and safety in the care home. Through this study, it is hereby possible for ABC care home to share good practice of record keeping and reporting in the care home, to provide clear strategy to other care homes in the country so that it would be possible to manage good record keeping activities in the institution.

Task 1 describing the legal and regulatory aspects of reporting and record-keeping in a care settin

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

All the records under reporting system are mandatory to be kept efficiently for further analysis of the performance of the care home, and it is the responsibility of the health care management team to ensure that the data and information are accurate and there is fairness in handling the record. Transparency and accountability are also essential to be managed well in the reporting system, so that the health and social care management team is able to share authentic and valid data to the CQC for analysing their organisational performance and the efficacy to provide quality patient care (Andriopoulou, Dagiuklas and Orphanoudakis, 2017). As per the CQC standard, the principles of recording the data and information are such as inoffensive, accurate and factual, clear and concise, understandable, relevant to the purpose and checkable, so that it would be easier for the health and social care professionals to review the data and patient information and develop further care plan and organisational strategy to maximise patient care in future. In addition to this, Health and Social Care Act 2008 is also another regulation implemented in the care home settings, in order to follow the ethical principles of CQC and manage the health care records and personal information of the patients efficiently. In this regard, the person centred approach and record keeping activities are maintained under regulations and the information related to medical reports, past treatment and care plan for the patients, internal environment of the care home, safety measures and accidental reports are managed well where the health and social care professionals must develop accurate record system, for analysing the organisational performance and patient care (Marutha, 2018). In this regard, the care home must provide the records related to employees’ records, policies and procedures, service and maintenance records, audits, reviews, purchasing documents and action plans in response to risks or incidents. In this regard, the Data Protect Act 1998 is mandatory to implement in the care home in order to manage the personal information and data efficiently. This regulation is further replaced by General data Protection Act 2018 to keep the data and information with safety and security. The electronics reports are protected through password and locked computerised system (Andriopoulou, Dagiuklas and Orphanoudakis, 2017). The staff members are also trained to manage the data and information efficiently and do not provide any access to unknown person for reviewing the personal information and internal data of the care home.

P2 Describing the regulatory and inspecting bodies’ requirements for reporting and record keeping in a care setting

Care Quality Commission or CQC provide suitable guidelines for successful record keeping and reporting of the care home, in order to manage their patients, staff and care professionals efficiently and run the institution sustainably. The major purposes of keeping medical records in the care home are such as managing accountability, decision making process innovation, contributing in the positive outcomes for the people receiving the services, capturing the important information which may be lost earlier, monitoring reviewing and quality assurance as well as promoting information exchange and communication (Gurupur et al., 2020). As per the guidelines of CQC, the record keeping activities must be developed through continuous monitoring and reviewing of the personal records such as need assessment, care plans, medical records and risk assessment. All the information related to these is mandatory to develop reporting at the care home. It is also mandatory to ensure that the records are accurate after effective patient assessment and it is stored in an organized way so that other health care professionals can identify the records and understand the health issues and treatment of a particular patient. Instructing the staff members in the care home is possible through reporting and record keeping strategy which must be up to date and accurate as per the patient assessment (Marutha, 2019). Additionally, it is essential to maintain dignity and confidentiality of the patients while record keeping process, so that the patients can feel safe while sharing their personal information and preferences. Hence, the CQC tries to enhance the standard of health and social care for promoting patients safety so that the information and personal data can be protected with safety and security. The care professionals try to gather personal information of the patients in the care home as well as protect it with CQC guidelines and health care regulations, so that it would be possible to improve trust and respect among the patients. For maintaining trust of the patients, managing confidentiality is necessary which further raises the safety level of the patients. Ethical practice is hereby mandatory where the care professionals try to involve the patients in the reporting system, where the patients are encouraged to share their personal information and data for developing reporting as well as ensure high quality health and social care services. The health care professionals also try to engage the family members, friends and care professionals to gather vast information about patient care, past treatment, personal preferences and other data related to the articular patient (Awogbami, Opele and Awe, 2020). In the care settings, the health and social care workers try to maintain confidentiality of the patients so that the individual can feel safe to share their information and stay healthily the care home and in this regard there is also the access of information to some selective person in the care home, such as doctors, nurses and health care managers, so that they can access the patient information for developing further care planning. Hence, information sharing is mandatory but it is also maintained with confidentiality to protect the personal information of the patients.

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

The issue of non-compliance is increasing over the period of time, for which the health and social care management team is facing problems for maximising the quality standard in the care home. It is the responsibility of the care home to protect compliance and maximise patient care by following ethical and legal structure. However, record keeping and reporting system is a critical task due to non-compliances or which the care professionals face issues in maintaining quality standard and running the institution fairly. There is lack of transparency and accountability in the care home which affect reporting activities negatively. The individuals do not follow the rules, ethical practice provided by CQC as well as laws related to health and social care which raise the issue of non-compliance (Andriopoulou, Dagiuklas and Orphanoudakis, 2017). Hence, it is high time for the care home to maintain compliances, and follow the legislative structure to run the health and social care institutions efficiently. For maintaining the quality standard by CQC, it is important to follow the ethical guidelines of record keeping tactics where the patient involvement is mandatory so that relevant data and information are recorded efficiently. Through following the record keeping process in the care home as well as the guidelines of protecting data and information are beneficial for the care home to maintain health records and the reporting related to safety measures at the workplace, staff management system and any accidental records in the care home. All the records must be kept efficiently under General Data Protection Act 2018 for further improvement of care home.

Task 2 exploring the internal and external recording requirements in a care setting

P3 Describing the process of storing of records in own care setting

There are several procedures of record keeping activities where the patient’s data and personal information are recorded efficiently in the care setting. The major steps of keeping record related to the patient are setting up a record retention, following the policies and procedures as well as maintaining accessibility, indexing and storage of the information, compliance auditing and disposal of obsolete records. Medical records are mandatory to be developed efficiently under data protection practice so that any external agencies cannot utilise the data and information for other purposes (Marutha, 2020). There is necessity of internal and external record keeping system, in order to maximise patient care. The family members have the right to identify the patient data and the power of attorney for the patients. If there is refusal of sharing the patient data with their family members, it is related to the issue of non-compliance, hence in such cases, sharing the information and patient data with external sources become mandatory. It is essential for the health care providers to maintain data and information of the patients regarding their current state of mind, health issues, treatment and care plan for improving patient safety and care. As per the NHS code of practice 2006, the health and social care professional have the scope to access the patient record for improving the quality of care so that they can be involved in the patient care plan and cooperate with each other for improving the wellbeing of the patients. There are different ways of keeping the data and information and recently, electronics documents are utilised massively across different health and social care institutions so that it would be possible to provide access of the relevant information and data to the care professionals (Luthuli, and Kalusopa, 2020). The electronics documentations are related to care plan of the patients, medicines, past treatment, nutrition and other documentation such as prescription and health reports.

P4 Explaining the reasons for sharing information within own setting and with external bodies

The major reasons for sharing information within own setting and with external bodies are to manage the patient care and improve the quality of care through continuous analysis and evaluation of the organisational activities. Through sharing the records with the internal bodies in care home, it is also possible to train the staff members and social workers where they can get overview of the patients and they try to involve in the care planning. Effective treatment, medicines and patient assessment are improved through record keeping system and sharing authentic information with the internal bodies. On the other hand, sharing information with the external bodies, sharing information is also beneficial for the care home to improve their legal compliance, maximise quality of care and ensure continuous improvement for further patient care and management (Modiba, Ngoepe and Ngulube, 2019). In the ABC care home, the major record keeping activities are conducted through managing different ways of keeping records. The organisation is efficient to maintain electronics records of the patients for successful patient care where the appointment of the patients, providing equal treatment and care, managing accountability is possible. Additionally, there are medical records and nursing records through processing notes which are also beneficial in the care settings for managing the individuals and providing them efficient treatment (Pikkarainen et al., 2018). On the other hand, medication charts and nutrition charts are also other activity of keeping authentic records of the patients. The laboratory orders and reports as well as patient handover sheets are also considered as important record keeping system of the patients in the care settings. Patient’s assessment firm is managed well as it is also important documents of keeping the authentic and value data and personal information of the patient in the care home. Moreover, discharge and transfer checklist and letters are also essential record keeping system for understanding patient care and developing further planning to deliver quality care and treatment to all the individuals in the care home.

P5 Accurately illustrating the internal and external requirements for recording information in own care setting

The internal record keeping system further includes chart notes, history of the patient, referrals, consultation letters, previous treatment and medications, and other medical reports, which are important for the care professionals to develop future care plan for the patient. Hence, there are several options of keeping the record of the patients efficiently and manage confidentiality further (Modiba, Ngoepe and Ngulube, 2019). On the other hand, external record keeping and sharing is also mandatory for the health and social care settings, where it is possible for the health care management team to make partnership with health care authorities, CQC and NHS to maintain guidelines and run the care home ethically. As per the Public Records Act 2005, the health and social care institutions are able to maintain the health records safely and protect the patient confidentiality successfully. Managing transparency and accountability while sharing the data and information is also essential for the health care management team, where the data would be authentic and relevant to the current situation of the care home. In the current scenario, the ABC care home is able to manage their activities in keeping the records safely and sharing it with the CQC in order to manage the organisational activities. By sharing the records with CQC, ABC care home is able to identify their strategies to maximise patient care and also get suitable suggestions from CQC to maintain the quality standard of their health and social care services.

Task 3 reviewing the use of technology in reporting and recording service user care

P6 Describing how technology is used in recording and reporting in own care setting

In the recent digitalized era, technology plays a crucial role, in order to manage the health and social care system and provide quality care to vast range of population in the country. Through technological device and database management system, the health care management team try to maintain digital information. Technology hereby makes the information record keeping perfect and efficient where the staff members are also trained through sharing the patient record and organisational information. It further maximises the patient care and improve the efficacy of the health care professionals to develop care plan for the individuals. New staff members in the car home can also follow the national policies and health care guidelines to access the information and protect patient confidentiality in long run (Luthuli, and Kalusopa, 2020). According to World Health organisation or WHO, technological record keeping system is beneficial for guiding the staff members in the care home as well as follows the track of the patients for creating further care plan. In such technology based record keeping system, the health and social care management team at the care home tries to involve the service users while the record keeping process is being conducted in the care home (Pikkarainen et al., 2018). For gathering the personal information and preferences, it is essential to involve the service users or the patients in the organisation, where the medical team in the care home tries to gather past medical records, recent medicines and treatment, personal mental and health issues faced by the individual and other related data which are utilised for successful patient assessment. Hereby, involving the patients in the record keeping processes is effective for the care home to maximise patient care and maintain patient confidentiality as well.

P7 Explaining the benefits of involving service users in record keeping processes

Digital medicines, different software like Compass Care and RIO are there to support the care home for protecting their health records and organisational data efficiently. In this regard, through the record keeping system, it is possible for the care home to manage their performance and maximise patient care in long run. In this regard, the computerised database system and password protected information are there to manage compliance and maintain transparency in the reporting system of the care home (Tanwar, Parekh and Evans, 2020). The software such as ERP, RIO and Compass care are effective to digitalise the health care system and ensure high quality record keeping system in future. Wireless sensor is also utilised through tableware and monitoring technology pieces are also effective in the care home, where the organisation tries to handle the authentic and valid information related to the patient and the organisational activities. The Information and Communication Technology or ICT is also implemented in the care home for enhancing internal communication, where the care professionals, social, workers and other health care staff try to access the important information from the digital record keeping system for enhancing their performance and productivity in the care home (Dimitrov, 2019). Access of information is also managed well where the health care managers provide access to a particular digital database so that the authorized person can manage confidentiality and also share important information with the care professionals.

M3 Review the use of digital technology in relation to own medical management procedures or care plan

The health and social care management team in the care home focus on developing integrate system of record keeping activity, where digital records are kept securely. In this regard, the computerised system at the workplace is effective to maintain the records and files related to the organisational practice and patient care. There is cloud computing system and database management system, where huge volume of data related to the patients and organisation are kept with safety. Additionally, there are iPads and Tablets through which the records are protected under the Data Protection Act 1998 (Marutha and Ngoepe, 2017). In addition to this, there are various diagnostics technologies such as Electroencephalogram or EEG, and Computerized Tomography CT scans where the patient data and reports of individuals are managed well under effective supervision and control. Moreover, the Enterprise resource planning or ERP is another major integrated system in the care home where the health care management team maintains a structure of the nursing home and manage resources for maximising efficiently. Through ERP, it is possible to maintain availability of the medicines, manage the health and professionals, reallocating the organisational resources and hiring exerts to control the overall system (Eichler et al., 2019). The technological advancement is beneficial for the care home to ensure confidentiality while managing the record keeping system in the care home. The technological advancement is hereby beneficial for the care home to manage their data and protect the information from any unauthorised use. In this regard, it is also beneficial for the health care managers to enhance the reporting strategy in own care settings. The organisational website and the database system are also effectively to manage information and personal data of the patients (Eichler et al., 2019). In the organisational website, there are also some data and important information related to the health care institution. On the other hand, the service providers in the care home can access the internal database for identifying the patient’s records to create further care plan.

Task 4 Maintaining records in a care setting in line with national and local policies and appropriate legislation

In order to manage record keeping system in a consistent manner, it is necessary for the health and social care professionals to manage the national polices and health care legislations which further help to manage organisational data and patient personal information safely. Ethical consideration and guidelines of CQC are applied in the care home for developing good records. For perfect record keeping system, the care professionals try to empower the patient and develop patient centred care plan, where the patients try to share their personal needs and preferences as well as the information about past treatment and care. This information is managed well through integrated computerised program, where the care homes try to implement digital database management system. The principles of the Nursing and Midwifery Council 2008 are also implemented well in the care home, for better management. There is implementation of Data Protection Act 1998 which is effective for protecting the data and information in the organisation (Marutha, 2020). The health and social care professionals also try to maintain password protected computers in order to manage patient confidentiality. The data authenticity and validity are also managed well, where the health care professionals try to share the relevant organizational data and patient information with the internal and external bodies. The internal staff members have the access to the information related to the patients as well as organizational information to work efficiently and create values for the patients. In addition to this, in the care home, the doctors also try to keep the health records of the patient through digital data management system, where the patients’ health condition, treatment and care plan are shared. On the other hand, the nutrition chart is also another major practice of keeping the records of the patients. As per the CQC guidelines, the doctors and the nurses in the care setting try to engage the family members of the patients and the patients themselves to share their personal needs so that the institutional data management can be conducted properly and it would also be possible for the care home to maximize patient care (Maphumulo and Bhengu, 2019). For further documentation, there is prescription and discharge or transfer letter, where the treatment and care plan of the patients are shared with the external bodies and also internal care professionals. Hence, the documentation process of the care home is beneficial to keep the records efficiently. on the other hand, the organizational information such as health and safety at the workplace, security system, emergency care efficiently, patient admission and care practices are shared through the organizational chart and computerized database management system, where the health care managers try to develop chart and annual report of the care home by implementing all the records related to the organizational operations. Hence, both the technical data management system and documentation are effective for the care home to maintain record keeping activities and reporting in the health care settings by following the CQC guidelines and health and social care policies.

Conclusion

It can be concluded that, record keeping activities, managing confidentiality and reporting are crucial in the health and social care settings where the health and social care management team is able to create values for the patients and also run the operations ethically. There is suitable guideline of CQC, as well as structured national policies and health care principals related to record keeping activities and reporting where the staff members try to act responsibly and follow the guidelines for successful record keeping and reporting in the care home. It is hereby beneficial for the care home to manage transparency and accountability in digital database management as well as share the important information with the internal and internal bodies so that it would be possible, to develop care plan for maximizing patient wellbeing in long run. The record keeping activities are important to manage information where technological advancement further improve the reporting style of the care home, where the health and social care management team is able to manage digital database system and could computing to maintain the records related to medical reports, personal care and management, organizational information safely under data protection principles.

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