Effective Reporting and Record-keeping in Health and Social Care Services (Unit 17)
Introduction
With the use of technology becoming more widespread, information is increasingly easy to obtain, store and retrieve. However, it is also becoming easy for the wrong people to have access to information. With increasing emphasis on accuracy and digital safety and taking into consideration the sensitive information recorded and used in healthcare settings, practitioners responsible for handling data or other information are expected to take the initiative on managing records appropriately and efficiently, reporting accurately to line managers.
This unit is intended to introduce students to the process of reporting and recording information in health, care or support services; it will allow them to recognise the legal requirements and the regulatory body recommendations when using paper or computers to store information, as well as the correct methods of disposing of records. This unit will enable students to recognise the importance of accurate recording and appropriate sharing of information and be able to keep and maintain records appropriately in their workplace.
Students will be expected to use appropriate methods to record and store information from their workplace and to follow data protection principles to use and dispose of the information on completion of tasks.
Students completing this unit will have developed the knowledge and skills to manage day-to-day recording and reporting which are essential to being an effective care practitioner and manager.
Learning Outcomes (LOs)
By the end of this unit students will be able to:
- Describe the legal and regulatory aspects of reporting and record-keeping in a care setting.
- Explore the internal and external recording requirements in a care setting.
- Review the use of technology in reporting and recording service user care.
- Demonstrate how to keep and maintain records in a care setting in line with national and local policies and appropriate legislation.
Any work submitted should include evidence of your research with references (Harvard Referencing)
Assignment Title: The use of reporting and record-keeping in ensuring safe and healthy environments for care
| Assignment Brief and Guidance |
Scenario 1:
(If you are a healthcare professional use your own organisation)
As a manager in ABC care home, you had recent visit from the CQC, and they reported that your relevant reports were up to date. However, a friend who happened to be a manager in another care home have had CQC visit, and failings were found in the areas of record keeping and reporting such as inaccurate medical records.
Also, fire safety records were not updated, and incidents were not reported either correctly in line with RIDDOR (Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013) or not reported at all. Moreover, service users’ data were not properly secured in line with The Data Protection Act 2018 (GDPR 2018).
As a result of these breaches, your friend has approached you to share some good practices with him to ensure that his care home was able to put their records in order to avoid closure of the care home.
Activity 1-
To support your friend effectively, you need to evaluate the consequences of non-compliance with reference to media, service user safety and the credibility of the care setting. Make sure to analyse them first.
For an effective evaluation and analysis, you must include a comprehensive description of the statutory as well as regulatory and inspecting bodies’ requirements for reporting and record keeping in own care setting.
Scenario 2:
(For this part, please use your own organisation)
| The care home where you work as an operations manager has invited an external trainer to come and train you and your team on the use of latest technology in reporting and recording information i.e. in line with the immediate development of emerging technology so that your team will continue to keep up to date with current trends in the sector. After the training, your directors have asked you to provide same training to new staff members. In the training session you will need to show some examples of some of the records you have kept in the organisation, how you have completed, processed and preserved those records and data in line with the organisational policy as well as local and national policies and guidelines. Note: For those already working in a health and social care organisation, you are strongly advised to use examples related to your own daily practice. Activity 2- Based on the above scenario, you need to evaluate and examine the arrangements and processes for storing records, sharing information and the internal and external requirements for recording information within your own place of work making recommendations for improvement. To support your evaluation, with reference to own care setting, you also need to explain the reasons for sharing information within own setting and with external bodies. This should be followed by reviewing the use of digital technology and evaluating its effectiveness in terms of meeting service user needs, ensuring appropriate care is given and maintaining confidentiality when recording and reporting in relation to own medical management procedures or care plan. You should also explain the benefits of involving service users in record keeping processes. Finally, you will need to produce accurate, legible, concise and coherent records regarding service user care for different service users following own setting’s guidelines and then evaluate their effectiveness in terms of meeting service user needs, ensuring appropriate care is given and effective reporting is carried out. |
You will have to analyse as well, the different aspects (processes) of own management (maintenance) of service user records with reference to compliance with national and local policies and guidelines, identifying any potential or actual difficulties
5000 Words
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