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Unit 4 Effective Reporting and Record Keeping in Health and Social care Services

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Effective Reporting and Record Keeping in Health and Social care Services

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Introduction Of Effective Reporting and Record Keeping in Health and Social care Services

The leak of the address, date of birth, and the names of the clinics to the media is one of the major issues through which the health care system of England is suffering and this is the reason it is very essential for the country’s healthcare system to have a robust record-keeping and reporting system for better future results. The following report will review the reporting and record-keeping system and processes for analyzing the issues and recommending better ways to enhance the processes.

Internal review of the reporting and record-keeping processes

The practices of the reporting and the record-keeping are very essential for the healthcare systems as well as for the patients. The utilization of the data is very essential for the enhancement of healthcare activities based on the needs of the patients and it also increases the level of perfection of the services (O'Donovanet al. 2017). In this healthcare setting the record-keeping and effective maintenance of the data is very essential as it supports the service providers to develop the healthcare services in favor of the patients. It is very essential to be understood that the medical records and information explains several details about the patients which include the history of the patient, diagnostic tests results, clinical findings, pre, and post-care conditions as well as the condition of the patient and this is the reason the leakage of this information can lead to the patient and family distress (Mutshatshiet al. 2018). Therefore, it increases the need for the development of an effective reporting and recording keeping system for the healthcare setting.

Reporting and the record-keeping are the only way through which it can be analyzed that the treatment of a patient was carried out effectively as the medical records are considered as the only source of truth from the side of the service provider and the leakage of such data to the media is the biggest loss in today’s environment (Zimmerman, 2019). The county council which is working under the guidelines of the NHS England is very responsible for the maintenance of the data in particular areas and maintains and manages multidisciplinary records related to healthcare and medication. The use of both hand-written and computer-based reporting and record-keeping processes are used by the organization for maintaining and managing the records in an effective manner (Newtonet al. 2019).

Some of the reporting and the record-keeping processes in the service area provision are listed below:

  • Up to date usage of the information systems and tools for the reporting and record-keeping and ensuring their security, confidentiality, and usage in an appropriate manner.
  • Password-protected systems are used which can only be accessed by the members of the healthcare organization and the accessibility is tracked regularly for analyzing the data about who and when accessed the information related to the patients.
  • Public displays are always avoided for making it clear that no unauthorized person can have access to the medical or patient records.

The usage of the Electronic Patient Record (EPR) is very much prominent in the organization for reporting and record-keeping processes as it is considered to be real-time, point-of-care and the approach is always patient-centric (Priestmanet al. 2018). This data is official data of the patient and can be transferred to the other departments of the healthcare settings for carrying out the process of treatment of the patient in an accurate manner. This presents the internal review of the reporting and record-keeping processes of the organization.

Effectiveness of work settings and processes and in terms of efficacy and compliance

Record-keeping is one of the most essential aspects in the care setting and maintaining the aspects of record-keeping around the laws and regulations are very essential for the organization to deal with the data ethically and confidentially which will help them to maintain efficacy and compliance (Lachanceet al. 2017). The work settings and processes of storing and sharing information indicate that the info ratio will only be shared with those who require the information it can either be the family or the patient itself or the caregiver (Doctor or nurse), no one else is authorized to use or access the information. The care setting carries confidential information related to the patient and this is the reason safeguarding this information is very important for the healthcare system, it is also the legal requirement of the system. In the work setting the reporting of the data is carried out with one relevant person assigned for the job and a person in authority is placed in a position in the care setting for the sharing of the information (Chico, 2018).

In the work setting processes, it is mentioned that the information handling is needed to be handled with care as it contains the protection and the use of the information of the person who is taking the healthcare services from the care setting. The Data protection act 1998 provides the most accurate guidelines related to information handling and maintenance and following this act is very essential for the care setting to maintain the efficacy and compliance of the data sharing and handling.The Data Protection Act 1998 contains four major processes which include the handling, recording, using, and disclosing the information, and the general data protection regulations are needed to be followed by the care setting for ensuring that the regulation and the sharing of the information are carried out in a confidential manner (Regulation, 2018).

In the care setting a registered person has been appointed on the set for the maintenance of the data in an effective manner who is subjected to keep the data safe and keep it away from the happening of misuse. The provision of the Health and Social care act 2008 is needed to be followed by the authorized person for keeping the record-keeping and reporting practices firm. The authorized person is needed to provide the reporting information of the day to the higher authority daily for ensuring extra and effective checks (Stirton, 2017). The care setting also follows the record-keeping and reporting aspects which are abided by the expectations of the national regulators for supporting the in-charge person for the data security and sharing. These aspects of the care setting provide the idea about the effectiveness of the work setting's arrangements and the processes of storing and sharing the information in terms of efficacy and compliance.

Evaluation of the consequences of non-compliance

In a care setting not maintaining the record and the data in an effective manner can lead to the development of a situation where the patient will face the issue of negligence from the care setting and this can lead to non-compliance situations (Colicchioet al. 2019). The non-compliance situations are the condition where the care setting is not able to comply with the regulations or the laws which have been developed by the governing body and in the healthcare system, the maintenance of the data or information is very essential for the care setting to take care of the data protection act and health and social care activities to stay in regulation with the compliance factors.

Not maintaining the record with the care setting in an effective manner is a negligence issue due to which even a patient can lose his or her life. The non-compliance with the record-keeping and reporting has been lead to severe criticism of the care setting and as observed in the scenario due to the leakage of the data in the media the families of the patients were harassed which can affect the licensing of the organization in the future. The losing of the data or inforka6tio related to the patient is one of the main reasons behind the degradation of the image of the care setting and this is the reason the organization needs to get the system the organization synchronized with the computer-based or electronic system which can help the organization ineffective maintenance of the information (Zimmerman, 2019). This is very essential for the care setting to keep an exclusive eye on the reporting and record-keeping system of the organization to keep an eye on the patient in an effective manner and keep every condition under check.

Some of the major consequences of the non-compliance are listed below:

  • Non-compliance is an issue that can result in hefty fines for the care setting and the fines regularly can erode huge impacts on the profit levels as well as can affect the healthcare system fund and maintenance. Non-compliance with the reporting and record-keeping in the care setting can lead to the breaching of the laws and regulations which have been made for the organization and the settlement with the lawsuit can impose very higher fines.
  • The damage to the reputation is the biggest consequence of the non-compliance and the non-compliance can put the organization in a bad light which is not required for the organization (Faruk, 2019). For an organization that is operating in the healthcare, sector non-compliance can affect the brand value of the organization adversely and the reputation of the organization can get a severe hit which is based on the severity of the non-compliance. This can lead to the loss of further opportunities for the organization and people would feel restricted from choosing the care setting in the future.

Recommendations for further improvement

Some of the recommendations for improving the setting in the future are listed below:

  • The care setting can use the Incident reporting system (IRS) in their clinical settings for the improvement of the managerial outcomes of the healthcare system. This is a double-loop learning program that can be used by the organization for handling the information related to the patients in an effective manner and reduce the error in the safety programs of the service users (Saeed and Jabbar, 2018). The IRS will include the chart notes and referrals which will help the care setting to gain the idea about the history of the patient and also help them to gain the clinical forms which can improve the existing performance of the organization in terms of data handling.
  • It is also recommended that the care setting is needed to implement a software-based approach for the collection and maintenance of the information which will include both reporting and record-keeping. The software-based approach will reduce the consequences of the ineffective system for the service user safety. This approach will keep the different outcomes in different sections which will enhance the information storing and sharing.
  • The use of the Fitbit application and the iPads and tablets, as well as computers for maintaining and managing the information in an effective manner and the use of the health management system application, is recommended for the organization as it will help them to enhance the effectiveness and credibility of the care setting to keep the information secured and the sharing of the information safe (McGhinet al. 2019). The use of technology in the reporting and record-keeping is very essential for the new employees of the organization as well. This can help the new staff to get the knowledge about the recording and reporting and keep the system effective and credible.
  • It is also recommended that the care setting should use the e-referrals and voice recognition system for maintaining the system stiff and coordinated as the organization needs to avoid the chances of lapse of the information to the media. Circulation of the information in the media sources can lead to a national leakage which can affect the patient as well as his or her family.


This report concludes that reporting, record-keeping, and effectively maintaining the data are some of the major things which are needed to be done effectively by the care setting. The internal review of the reporting and record-keeping processes and their effectiveness interns of the efficacy and compliance is discussed in the above report. This also concludes that for effectively following the compliance regulations the organization needs to follow the Data protection act 1998. Hefty fines and low image are two of the issue which are affected if the organization is observed to have non-compliant activities related to its recording and reporting functions.


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Colicchio, T.K., Cimino, J.J. and Del Fiol, G., 2019. Unintended consequences of nationwide electronic health record adoption: challenges and opportunities in the post-meaningful use era. Journal of medical Internet research21(6), p.e13313.


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Zimmerman, D.H., 2019. Record-keeping and the intake process in a public welfare agency. In On record (pp. 289-321). Routledge.

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