Record Keeping in Health and Social care Environmental Economics 7401ENV

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UNIT 17/AB/ SEPT
ASSIGNMENT BRIEF
STUDENT NAME AND ID
NUMBER
Qualification
Pearson BTEC Level 4 Higher National Certificate and Level 5
Higher National Diploma in Healthcare Practice for England
ACADEMIC YEAR
2020-2021
Unit 4 (CORE UNIT)
Effective Reporting and Record Keeping in Health and Social care
Services
UNIT TUTOR
Dr Naveed Akbar; Dr Maria Iyekekpolor
Assignment Title
The use of reporting and record-keeping in ensuring safe and
healthy environments for care
Type of Assignment
Report
Weighting
100%
Issue Date
Week commencing 31st May 2021
Formative Submission
Date
Week commencing 14/06/2021 (14th June 2021 by 14:00 using
the Formative Submission link on Moodle)
Summative Submission
Date
Week commencing 28/06/2021 (28th June 2021 by 14:00
using the Summative link onMoodle)
Assessor
Dr Naveed Akbar; Dr Maria Iyekekpolor
IV
Dr Rhyddhi Chakraborty
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UNIT 17/AB/ SEPT
Student Declaration
This is to confirm that this submission is my own work, produced without any external help except
acceptable support from my lecturer. It has not been copied from any other person’s work (published
or unpublished), and has not previously been submitted for assessment either at GBS or elsewhere.
I confirm that I have read and understood the ‘GBS Academic Good Practice and Academic
Misconduct: Policy and Procedure’ available on Moodle.
I confirm I have read and understood the above Student Declaration.
Student Name
(print)
Signature
Date
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UNIT 17/AB/ SEPT
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.
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UNIT 17/AB/ SEPT
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.
LO3 Review the use of technology in reporting and recording service user care
in a care setting.
LO4 Demonstrate how to keep and maintain records in own care setting in line
with national and local policies.
Submission Format
This work consists of two activities:
Activity 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 word count for activity 1 is 2000 words.
Activity 2
Requires the submission of evidence from a simulated 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 an audio or video recording of the event
where you will demonstrate you have evaluated the effectiveness of your own completion of relevant
records.
The word count for activity 2 including the presentation and speaker notes is 1500.
This unit 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.
For both activities, 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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Assignment Brief and Guidance
Scenario 1
In 2020, 237 million medication errors were recorded in England and affecting over 1700
lives (BMJ,2020). In 2019, a leak of address, date of birth, and clinic names to the media by
NHS Highlands was in breach of 40 HIV patients’ privacy. It caused distress to patients and
their families.
As part of the plan to have a robust health care system in England, the director of healthcare
services requests you to conduct a Self-Assessment.
To do this, review the reporting and record-keeping requirements and processes in an area
of service provision in your setting. These would be for the induction of new healthcare staff
into your organisation.
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 (LO1) 500 words.
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 (LO1)
500words.
You will include an evaluation of the consequences of non-compliance with legal and regulatory
aspects of reporting and record keeping in the setting (LO1) 500 words.
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 (LO1) 500 words.
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.
Scenario 2:
The Director of HealthCare services is pleased with the review. You are to conduct one of the
training sessions for newly recruited staff. The session will train staff on using technology for
reporting and recording service user care in your setting. You are to provide staff with a
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UNIT 17/AB/ SEPT
demonstration of how specific records are completed, processed, and stored in your organization.
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 setting, explaining how you completed, processed, and stored
these records in line with the setting’s policy, local, and national policies and guidelines.
Activity 2:
Produce a set of training materials on record-keeping for new staff (LO2) 500 words.
These materials will include an electronic presentation 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 (LO3) 500 words.
You will also include an activity that provides the trainees with 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, ensuring appropriate care is given and that effective reporting is
carried out, to facilitate their understanding (LO4) 500 words.
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UNIT 17/AB/ SEPT
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
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.
D2 Evaluate own work setting’s
arrangements and processes for
storing and sharing information,
making recommendations for
improvement.
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.
M3 Review the use of digital
technology in relation to own
medical management procedures
P7 Explain the benefits of
involving service users in record
keeping processes.
or care plan.
LO4 Demonstrate how to keep and maintain records in own
care setting in line with national and local policies
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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.
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.
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Academic Integrity (Note to avoid Plagiarism)
Academic integrity is a fundamental expectation for all college/university students and while it
is acknowledged that mitigating circumstances might be raised as factors in student behaviour,
cheating cannot be disregarded. GBS definition of plagiarism, as contained in GBS Academic
Good Practice and Academic Misconduct Policy and Procedure, has been expanded to make
explicit that copying from texts or web sources and copying work from other students
constitutes plagiarism.
“Plagiarism is the act of taking or copying someone else’s work, including another student’s,
and presenting it as if it were your own. Plagiarism is said to occur when ideas, texts, theories,
data, created artistic artefacts or other material are presented without acknowledgement so
that the person considering this work is given the impression that what they have before them
is the student’s own original work when it is not. Plagiarism also occurs where a student’s own
work is re-presented without being properly referenced. Plagiarism is a form of cheating and is
a disciplinary offence.”
Plagiarism is easy to avoid by making sure you reference all of the sources of material that you
use in the completion of your work. Pearson has developed Guidelines on Harvard
Referencing which are available in Academic Support Area for Students on Moodle (VLE) as
well as on respective unit pages.
If you are concerned about referencing techniques, please draw the matter to your Unit
Lecturer or Academic Support Team on academicsupport@globalbanking.ac.uk so that you
may receive extra advice.
Group coursework may be designed so that the contribution of each student is identifiable but
inclusion of plagiarised material is still the responsibility of the whole group. All members of the
group should exercise vigilance to ensure that work is properly referenced; in group- work,
students have a shared responsibility for the assignment.
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UNIT 17/AB/ SEPT
Textbooks
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
Reports and Journals
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
Websites
hcpc.org.uk Health and Care Professions Council
Health record and communication practice
standards for team based care. NHS Information
Standards Board, 2004.
(Guidance)
Recommended Resources

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