Effective Reporting and Record-keeping in Health and Social Care Services

Effective Reporting and Record-keeping in Health and Social Care Services

Effective Reporting and Record-keeping in Health and Social Care Services

Submission Format

This work will be submitted in 2 different formats: Assessment 1 should be submitted as a word-processed report document in a standard report style, which requires the use of headings, titles and appropriate captions. You may also choose to include pictures, graphs and charts where relevant to support your work. The recommended word count for this assignment is 1500–2000 words, though you will not be penalised for exceeding this total. Assessment 2 requires the submission of evidence from a mock training event on record- keeping. This will include a set of materials used in the event, to include an electronic presentation, evidence of your own record-keeping across a range of types of records, as well as where you will demonstrate you have evaluated the effectiveness of your own completion of relevant records. The recommended word count for the presentation is 1000–1500 words (including speaker notes), though you will not be penalised for exceeding this total. For both assessments, any material that is derived from other sources must be suitably referenced using a standard form of citation. Provide a bibliography using the Harvard referencing system.

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Unit Learning Outcomes

LO1 Describe the legal and regulatory aspects of reporting and record keeping in a care setting LO2 Explore the internal and external recording requirements in a care setting

Assignment Brief and Guidance

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Purpose of this assignment: The purpose of the assignment is to assess the learner firstly in relation to both the legal and regulatory aspects of reporting and record keeping in a care setting through producing an internal evaluative review of record keeping in their own care setting. Secondly, the learner will be assessed on the internal and external recording requirements in a care setting. Thirdly, the learner will be assessed on Review the use of technology in reporting and recording service user care in a care setting and fourthly the learner will demonstrate how to keep and maintain records in own care setting in line with national and local policies. Breakdown of assignment: Assignment:

You need to produce one written piece of work of 2,500 words (+/- 10%) covering all the

assessment criterion in LO1-LO4 as one document.

Unit Learning Outcomes

LO1 Describe the legal and regulatory aspects of reporting and record keeping in a care setting LO2 Explore the internal and external recording requirements in a care setting

Assignment Brief and Guidance

Scenario: You are a manager in a local authority setting providing residential and non-residential care services to individuals with specific needs. There have been several recent articles in the news regarding the ‘unnecessary’ death of a patient in a local hospital. The media reports that there was a catalogue of procedural errors in record-keeping in the hospital that led to the patient’s death. These included incorrect medicine dosage, missed patient observations due to inaccuracies in shift records, and an incident with the patient’s family reporting the patient’s chest pains not being recorded. In addition, the patient’s family was refused access to their health records, despite the family member requesting the records being authorised by the patient through a lasting power of attorney. Lastly, the personal details of the patient were leaked to the media by someone who journalists report worked at the local hospital. As a result of this, and several other breaches in protocol and practice, the Secretary of State for Health has ordered the national regulator to conduct a review of the data management processes and procedures across all health and social care provision in their remit. To facilitate this, your Director has tasked you with conducting a Self-Assessment Review of the reporting and record-keeping requirements and processes in an area of service provision in your setting, to be used in a series of training sessions to be given to all the care workers that are new to your organisation

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Activity 1:

For this activity, you will produce an evaluative internal Review of the reporting and record- keeping processes in an area of service provision in your setting. Your Review will be confidential, and evaluate how effective your work setting’s arrangements and processes for storing and sharing information are, in terms of efficacy and compliance. Your Review will put forward recommendations for how your setting can improve its processes, with reference to the consequences of ineffective systems for service user safety, the setting’s effectiveness and credibility and with reference to the media.

LO2 Explore the internal and external recording requirements in a care setting

Scenario

You have been asked by your Manager to produce some induction material for new staff. They are concerned with introducing new staff to material related to Compliance in Health and Social Care settings. The theme that they want you to focus on is relevant legislation and protocols to refer to as a new team member.

Activity 2

They have requested that you submit information in report format covering key legislation, guidelines and you will include an evaluation of the consequences of non-compliance with legal and regulatory aspects of reporting and record keeping in the setting. protocols that relate to Effective Reporting and Record Keeping in Health and Social Care.

Unit Learning Outcomes

LO3 Review the use of technology in reporting and recording service user care in a care setting Scenario With the increasing use of technology in the workplace, an inspirational manager needs to examine the uses of technology in a healthcare setting and be able to guide their team through both the procedural use of and the ethical issues surrounding recording and reporting using technology. This assignment will provide you with the opportunity to not only demonstrate your knowledge of record-keeping and reporting in a variety of situations, but also to produce a relevant, accurate set of documents to evidence your skills. : As a result of your review, your Director has asked that you run one of the training sessions for new staff. The session will train new staff on the use of technology for reporting and recording service user care in your setting, providing the staff with a demonstration of how specific records are completed, processed and stored in your setting. As part of the training session, you are to provide the staff with a range of anonymised examples of the records you have kept in the

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setting, explaining how you completed, processed and stored these records in line with the setting’s policy, local and national policies and guidelines. Activity 3: Produce a set of training materials on record-keeping for new staff. These materials will include an electronic presentation using Powerpoint or Prezi that evaluates the effectiveness of the use of technology in the setting in terms of meeting service user needs, ensuring appropriate care is given and maintaining confidentiality. You need to include anonymised examples of how records are completed from your own practice. LO 4: Apply law and policy in line with regulatory and ethical requirements in a relevant practice setting. Scenario You have been approached by a care provider as an independent Consultant to provide a briefing to a Care Home staff team that has recently received a Poor CQC report. Part of the reason for this was that record keeping was found to be requiring improvement. The care provider wants you to submit your briefing in the form of a report and include examples of your own record keeping practice. Activity 4 In your report, you firstly need to explain the ethical and regulatory context of record keeping in relation to Health and Social Care, giving attention to the role of the CQC and the connection between different Ethical Principles and good record keeping. You will also include in your report examples of records you have kept, during which you will evaluate the effectiveness of your own completion of records in terms of meeting service user needs, compliance with organisational and other relevant policies, ensuring appropriate care is given and that effective reporting is carried out, to facilitate their understanding. **In your submissions, you must remember the need for absolute confidentiality. This means you need to change the details of the location, the name of the setting, as well as all details relating to patients/service users, practitioners and other staff.

*Please access HN Global for additional resources support and reading for this unit. For further guidance and support on report writing please refer to the Study Skills Unit on HN Global www.highernationals.com

Learner declaration

I certify that the work submitted for this assignment is my own and research sources are fully acknowledged.

Student signature: Date:

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Learning Outcomes and Assessment Criteria

Pass Merit Distinction

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

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

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

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

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

LO2 Explore the internal and external recording requirements in a care setting

D2 Evaluate own work setting’s arrangements and processes for storing and sharing information, making recommendations for improvement

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

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

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

M2 Examine the current processes in own care setting related to storing and sharing records

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

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

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

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

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

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

D4 Evaluate 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

P8 Produce accurate, legible, concise and coherent records regarding service user care for different service users following own setting’s guidelines

P9 Explain different aspects of own management of service user records with reference to compliance with national and local policies and guidelines

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

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Remember to keep evidence of your submitted coursework

Learning Support Resources

Indicative Reading: LILLYMAN, S. and MERRIX, P. (2012) Record Keeping (Nursing and Health Survival Guides). Oxford: Routledge. WHELAN, A. and HUGHES, E. (ed.) (2016) Clinical Skills for Healthcare Assistants and Assistant Practitioners. Oxford: Wiley Blackwell IPSOS MORI (2013) E-readiness in the social care sector for SCIE: Final report. Department of Health (2012) Digital Strategy: Leading the culture change in health and care Scott B. (2004) Health record and communication practice standards for team based care. NHS Information Standards Board www.ico.org.uk Information Commissioners Office 1. Guide to Data Protection 2. Data Sharing Code of Practice (Training) www.nmc.org.uk Nursing and Midwifery Council 1. The Code for Nurses and Midwives 2. Guidelines for Records and Record-keeping (Guidance) www.nursingtimes.net Nursing Times The importance of good Record-keeping for nurses (Article) Other online resources: www.ico.org.uk Information Commissioners Office 1. Guide to Data Protection 2. Data Sharing Code of Practice (Training) www.nmc.org.uk Nursing and Midwifery Council 1. The Code for Nurses and Midwives 2. Guidelines for Records and Record-keeping (Guidance) www.nursingtimes.net Nursing Times The importance of good Record-keeping for nurses (Article)

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Essay terms explained To write a good essay, firstly you need to have a clear understanding of what the essay question is asking you to do. Looking at the essay question in close detail will help you to identify the topic and ‘directive, which instruct you how to answer the question. Understanding the meaning of these directive words is a vital first step in producing your essay.

Essay term Definition Analyse Describe the main ideas, showing their relationships and significance where you need to

break an issue into its constituent parts. Look in depth at each part using supporting arguments and evidence for and against as well as how these interrelate to one another.

Assess Consider the value of, paying attention to positive/negative aspects where you need to

weigh up to what extent something is true. Present your argument by citing relevant research and also point out any flaws and counter-arguments as well. Conclude by stating clearly how far you are in agreement with the original proposition.

Compare Look for similarities and differences on any one or more phenomena. Compare’ and

‘contrast’ is often associated with many questions.

Contrast You need to explore the dissimilarities or the points set in opposition in order to bring out the differences. This is similar to compare but you need to focus on the dissimilarities between two or more phenomena. Point out any differences which are particularly significant.

Evaluate/ Critically evaluate

Here you need to put your argument or verdict so as to explain on what extent a statement or findings within a piece of research are true. Hence in this type of questions, you need to provide evidence taken from a wide range of sources which both agree with and contradict an argument but at last you need to come to a final conclusion, basing your decision on what you judge to be the most important factor.

Examine Here you need to give close attention and establish the key facts and important issues surrounding a topic. Here you can do critical evaluation and you should try and offer reasons as to why the facts and issues you have identified are the most important.

Define You need to give a precise term which can explain the meaning of the required term & problem.

Demonstrate Here you need to illustrate, show or to practically visualise an actions or activity. This type

of question can be associated with witness testimony or observation report.

Discuss Here you need to write case for and against an argument like a debate but do use your

reasoning skills too to point out the advantages and disadvantages on a given context and also support with your conclusion.

Explain Here you need to clarify a topic by giving a detailed coverage as to how and why it occurs,

or what is meant by the use of this term in a particular context. Your writing should cover key terms where appropriate, and be validated with appropriate research.

Explore You need to represent variety of different viewpoints by adopting a questioning approach

and synthesise joined views of different points.

Identify Here you need to state the key points to be addressed and implications thereof.

Review Look thoroughly into a subject. This should be a critical assessment and not merely descriptive.

Interpret Here you need to present your understanding on an issue or topic. You view point towards any research and comments why?

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Justify Make a case by providing a body of evidence to support your ideas and points of view. In order to present a balanced argument, consider opinions which may run contrary to your own before stating your conclusion.

Outline Present with the main points placing emphasis on main findings and interrelationships with

the questions/ topic asked (Don’t go into detail).

Summarise Provide a shortened form illustrating out the focal/main facts and neglect unnecessary

information. Brief or over-all illustrations/ examples will normally serve for this kind of answer.

Describe This term is associated with covering detailed explanation as to how and why something

happens.

Effective Reporting and Record-keeping in Health and Social Care Services

Effective Reporting and Record-keeping in Health and Social Care Services