Overview of the Module

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 recognize 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 recognize 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

By the end of this unit students will be able to:

1 Describe the legal and regulatory aspects of reporting and record-keeping in a care setting.

2 Explore the internal and external recording requirements in a care setting.

3 Review the use of technology in reporting and recording service user care.

4 Demonstrate how to keep and maintain records in a care setting in line with national and local policies and appropriate legislation.

Essential Content

LO1 Describe the legal and regulatory aspects of reporting and record-keepingin a care setting

Statutory requirements and guidelines

Legislation: Data protection e.g. General Data Protection Regulations (2018) and principles, Freedom of Information Act (2000), Human rights e.g. Human Rights Act (1998), OR data protection and human rights legislation as currently applicable in own home country

Statutory guidance, e.g. The Caldicott Report and Principles (1997), Health and Social Care Information Centre Code of Practice on Confidential Information (HSCIC, 2014), Information Commissioner’s Office Data sharing code of practice(ICO, 2016), OR other governmental body requirement as currently applicable in own home country

Regulatory and inspecting bodies requirements.

The Fundamental Standards of Care, or equivalent as applicable in own homecountry

Regulatory Bodies’ Professional Standards and Codes of Conduct Inspecting body requirements e.g. Care Quality Commission (CQC) Implications of failing to comply

Enforcement notices, monetary penalty notices, or other legal action Audit

Credibility of work place

Own professional credibility Termination of contract Media response

Consequences for the individual e.g. loss of trust in services, loss of dignity, privacy and respect

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

Purpose of recording information

Paper documents, e.g. clinical notes, accident and incident reports and statements, meeting minutes or notes, risk assessments, visitor and staff logs Patient information, electronic or written e.g. care plans, nutrition recording,medicines recording, documents for requesting and reviewing tests

Electronic documents, e.g. laboratory reports, letters to and from other professionals, emails, text messages

Information systems/databases

Other recording and reporting media, e.g. x-rays, photographs, videos, tape recordings of telephone conversations, print outs from monitoring equipment.

Information transmitted verbally

Differences between different classes of information and confidentiality requirements of each

Public information Private and personal Confidential Restricted

Internal and routine business

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

Maintaining confidentiality

Secure systems for recording and storing information

Processes and procedures regarding the storage of records, e.g. electronic, paper, laptops, memory sticks, home working, information in transit, encryptionof data, access privileges

Errors in recording and reporting

The importance of accuracy in recording data

The use of sampling for quality standards

Consequences of errors, e.g. risk to service users, loss of reputation, loss of credibility, financial penalties and prosecution

Retention and disposal of records

Expectation regarding maintenance of records, e.g. time boundaries Accessibility of electronic records

ü  Disposal of records, e.g. shredding, pulping, burning, use of specialist services

ü  Purpose of sharing information

ü  Identifying objectives

ü  Consent from service users and/or their advocate/s

ü  Implications of sharing without individuals’ knowledge and consent

ü  Sharing with personnel, e.g. other professionals providing care, staff involved in investigation of complaints, audits or research

ü  Following appropriate court documentation

ü  Sharing statistics

ü  Sensitive information

ü  Service user queries and complaints

ü  Public health investigations

ü  ICO data sharing code of practice, e.g. express obligations, express powers, implied powers

ü  Internal recording requirements

ü  Medical history

ü  Tests

ü  Treatment, e.g. anaesthetics reports, surgery records

ü  Clinical incidents, complaints

ü  Diagnosis

ü  Medical management plan

ü  Service user care forms

ü  Telecare recording

ü  Telephone consultations, clinician and other specialists’ call

ü  Frequency of recording, timescales

ü  Signatories

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

External recording requirements

ü  Health and safety: reporting accidents and incidents, requirements of legislation relevant to the recording of information relating to health and safety, e.g. The Health and Safety at Work, etc. Act (1974), Management of Health and Safety at Work Regulations (1999), Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (1995), Workplace (Health, Safety and Welfare) Regulations (1992)

ü  Role of public bodies, e.g. The Health and Safety Executive, CQC, local authorities

ü  Child or adult protection requirements

ü  Reporting concerns

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

in a care setting

ü  Digital working

ü  Care plan applications using new technologies e.g. on smartphones

ü  Use of tablets to record

ü  Virtual consultations, through online software application

ü  Other current examples of the use of digital technologies in care

ü  Digital technology safety guidelines

ü  Data breach

ü  Sharing on incompatible software

ü  Involving service users in the process

ü  Principles of co-production and co-management

ü  Empowering care choice

ü  Access to information

ü  National Institute for Care and Excellence (NICE) guidance

Benefits of digital working

ü  Flexibility of access

ü  Improved communication and information sharing

ü  Resource savings

ü  Efficiency

ü  Currency of information

ü  Barriers to digital working

ü  Cost

ü  Training implications

ü  Software updates

ü  Staff and service user apathy or lack of skills

ü  Ethical issues

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

ü  Features of effective records

ü  Up to date

ü  Complete

ü  Accurate, understandable and legible

ü  Timely

ü  Clear and concise

ü  Using appropriate digital technology

ü  Completing to support the delivery of high-quality care

Typical types of records completed in care practice.

ü  Timesheets and rotas

ü  Cleanliness and hygiene records

ü  Minutes of meetings                     

ü  Recording nutritional status

ü  Recording progress or change

ü  Recording interventions

ü  Recording episodes of care

ü  Administration of medication

ü  Recording changes to care routine/agency e.g. transfers of care

ü  Recording adverse events and confrontations

ü  Reporting incidents, accidents or near misses

ü  Using sound numeracy skills

ü  In day-to-day administration and management of records

ü  In recording information regarding nutrition and fluid balance

ü  In monitoring routine activity

ü  In medication management

ü  In relation to accurate medicines calculations

ü  In recording and interpreting physiological data, e.g. graphs and charts

ü  Responding to vulnerable individuals in medication management

ü  In filing and storing information

ü  Maintaining records

ü  Secure storage of information and data

ü  Secure transference of records

ü  Accessibility

ü  Recognising and responding to errors and issues

ü  In recording and reporting

ü  In maintaining confidentiality

ü  In maintaining securit

ü  Responsibilities of different staff

ü  Notifying others

ü  Whistleblowing

Descriptors

To achieve a Pass for each unit, the learner must achieve each of the learning outcomes and associated assessment criteria. The assessment standard for a Pass is inherent within each of the assessment criteria and is determined in part by the command verb used, e.g. ‘evaluate different approaches. To achieve a Merit grade for a unit, students must achieve all the Pass criteria and all Merit grade descriptors (M1, M2, M3, M4).

For a Distinction grade for a unit, students must achieve all of the Pass criteria, all Merit grade descriptors (M1, M2, M3, M4) and all Distinction grade descriptors (D1, D2, D3, D4). Students achieve each grade descriptor by providing evidence of at least one indicative characteristic identified by the assessor for each grade descriptor. In other words, students cannot achieve the Distinction grade if they have not evidenced all Pass and Merit elements.

The assessment on this unit will be made based on submitting an assignment of approximately 3000 in total with +/- 10% margin. LO1 Describe the legal and regulatory aspects of reporting and record-keeping in a care setting.