EFFECTIVE REPORTING AND RECORD-KEEPING IN HEALTH AND SOCIAL CARE SERVICES

 1
EFFECTIVE REPORTING AND RECORD-KEEPING IN HEALTH AND SOCIAL CARE
SERVICES
Name
Affiliation
Date
2
Table of Contents
Introduction:.................................................................................................................................... 3
Legal and Regulatory Aspects: ....................................................................................................... 3
Consequences of Non-Compliance:............................................................................................ 5
Requirements of Internal and External Recording: ........................................................................ 5
Review of Technology Use:............................................................................................................ 7
Application of Law and Policy with Regulatory and Ethical Requirements:................................. 8
Conclusion: ................................................................................................................................... 10
References..................................................................................................................................... 11
3
EFFECTIVE REPORTING AND RECORD-KEEPING IN HEALTH AND SOCIAL CARE
SERVICES
Introduction:
Practices for reporting and record-keeping are important in healthcare. These activities are also
useful in the social care field. The field is very delicate that the use of data or information can
ensure perfection and a high level of effectiveness of activities. In the healthcare setting, the
importance of record-keeping and maintaining is of high importance because it helps to make
decisions in favor of patients. It is not by choice to ensure record-keeping in the areas of health
and social well being (ICO.org, 2018). Legal and regulatory parameters in health and social care
are strict, so that it remains under the limits of law and legislation. In this context, requirements
for recording may not necessarily link with external aspects, but they also have a link with the
internal environment of a care setting. In the application of regulatory and legal aspects of the
practice, it is worthwhile to consider and implement technology in record-keeping practices
along with reporting mechanisms so that it can serve the purpose of a care setting (Wright,
2013). Therefore, a care setting should abide by law and regulations and it should ensure recordkeeping and reporting by keeping local and national policies in view. This paper has taken all
these perspectives about records and information management in the care setting.
Legal and Regulatory Aspects:
A scenario helps to answer on legal and regulatory aspects in the given case that the Secretary of
State for Health has ordered the national regulator to compile a report on data management and
process in health and social care centers. The description of related aspects around law and
regulations would help the care setting to know these aspects in its practices.
Aspects of record-keeping around law and regulations call for dealing with information
confidentially and ethically. The information-sharing should take place with people who require 
4
that information. A care setting contains highly personal information about a person, and its
protection is a legal and regulatory requirement. It also increased the level of trust and increased
the level of safety for patients. In a particular case or scenario, the record-keeping was centrally
important for the health and life of the patient. Moreover, reporting of data should also take place
with relevant people (Wright, 2013). It is a regulatory obligation of a person in authority in a
care setting to share the information. That person may be an individual's neighbor, friend, family
member, professional taking care of the individual, any social or health care workers, and any
other individual or worker who is fulfilling the responsibility of providing social and health care
to an individual in a care setting (ICO, 2017).
It is also a legal and regulatory requirement that information handling takes place with care.
Handling of information is important because it would involve protection and authentic use of
the information of any individual taking health and social care. Practices for keeping and
maintaining records or information make an inevitable part of health care delivery that is part of
the personal practice activities. Some laws and legislations may help to know why it is necessary
to keep records and report it. Data protection act 1998 offers guidelines in this regard. There are
general data protection regulations or GDPR, which are helpful in this regard. Data protection act
1998 ensures the protection of information obtained in the healthcare setting. The processes of
holding, recording, using, and disclosing information make the whole process of data protection.
The whole process is part of the dat