1 | P a g eUNIT 17/AB/ SEPTASSIGNMENT BRIEF STUDENT NAME AND IDNUMBERQualificationPearson BTEC Level 4 Higher National Certificate and Level 5Higher National Diploma in Healthcare Practice for EnglandACADEMIC YEAR2020-2021Unit 4 (CORE UNIT)Effective Reporting and Record Keeping in Health and Social careServicesUNIT TUTORDr Naveed Akbar; Dr Maria IyekekpolorAssignment TitleThe use of reporting and record-keeping in ensuring safe andhealthy environments for careType of AssignmentReportWeighting100%Issue DateWeek commencing 31st May 2021Formative SubmissionDateWeek commencing 14/06/2021 (14th June 2021 by 14:00 usingthe Formative Submission link on Moodle)Summative SubmissionDateWeek commencing 28/06/2021 (28th June 2021 by 14:00using the Summative link onMoodle)AssessorDr Naveed Akbar; Dr Maria IyekekpolorIVDr Rhyddhi Chakraborty 1 | P a g eUNIT 17/AB/ SEPTStudent Declaration This is to confirm that this submission is my own work, produced without any external help exceptacceptable support from my lecturer. It has not been copied from any other person’s work (publishedor unpublished), and has not previously been submitted for assessment either at GBS or elsewhere.I confirm that I have read and understood the ‘GBS Academic Good Practice and AcademicMisconduct: Policy and Procedure’ available on Moodle.I confirm I have read and understood the above Student Declaration.Student Name(print)SignatureDate 4 | P a g eUNIT 17/AB/ SEPT INTRODUCTIONWith the use of technology becoming more widespread, information is increasingly easy toobtain, store and retrieve. However, it is also becoming easy for the wrong people to haveaccess to information. With increasing emphasis on accuracy and digital safety and takinginto consideration the sensitive information recorded and used in healthcare settings,practitioners responsible for handling data or other information are expected to take theinitiative on managing records appropriately and efficiently, reporting accurately to linemanagers.This unit is intended to introduce students to the process of reporting and recordinginformation in health, care or support services; it will allow them to recognise the legalrequirements and the regulatory body recommendations when using paper or computers tostore information, as well as the correct methods of disposing of records.This unit will enable students to recognise the importance of accurate recording andappropriate sharing of information and be able to keep and maintain records appropriately intheir workplace. 4 | P a g eUNIT 17/AB/ SEPT Unit Learning OutcomesLO1 Describe the legal and regulatory aspects of reporting and record keepingin 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 carein a care setting.LO4 Demonstrate how to keep and maintain records in own care setting in linewith national and local policies.Submission FormatThis work consists of two activities:Activity 1Should be submitted as a word-processed report document in a standard report style, which requiresthe 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 2Requires the submission of evidence from a simulated training event on record-keeping. This willinclude a set of materials used in the event, to include an electronic presentation, evidence of your ownrecord-keeping across a range of types of records, as well as an audio or video recording of the eventwhere you will demonstrate you have evaluated the effectiveness of your own completion of relevantrecords.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 recordkeeping and reporting in a variety of situations, but also to produce a relevant, accurate set ofdocuments to evidence your skills.For both activities, any material that is derived from other sources must be suitably referenced using astandard form of citation. Provide a bibliography using the Harvard referencing system. 4 | P a g eUNIT 17/AB/ SEPT Assignment Brief and GuidanceScenario 1In 2020, 237 million medication errors were recorded in England and affecting over 1700lives (BMJ,2020). In 2019, a leak of address, date of birth, and clinic names to the media byNHS Highlands was in breach of 40 HIV patients’ privacy. It caused distress to patients andtheir families.As part of the plan to have a robust health care system in England, the director of healthcareservices requests you to conduct a Self-Assessment.To do this, review the reporting and record-keeping requirements and processes in an areaof service provision in your setting. These would be for the induction of new healthcare staffinto your organisation.Activity 1:For this activity, you will produce an evaluative internal review of the reporting and record-keepingprocesses 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 andprocesses 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 regulatoryaspects 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, withreference to the consequences of ineffective systems for service user safety, the setting’seffectiveness 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 examinethe uses of technology in a healthcare setting and be able to guide their team through both theprocedural 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 thetraining sessions for newly recruited staff. The session will train staff on using technology forreporting and recording service user care in your setting. You are to provide staff with a 4 | P a g eUNIT 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 examplesof the records you have kept in the setting, explaining how you completed, processed, and storedthese 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 useof technology in the setting in terms of meeting service user needs, ensuring appropriate care isgiven 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 ofmeeting service user needs, ensuring appropriate care is given and that effective reporting iscarried out, to facilitate their understanding (LO4) 500 words. 9 | P a g eUNIT 17/AB/ SEPT Learning Outcomes and Assessment CriteriaPassMeritDistinctionLO1 Describe the legal and regulatory aspects of reporting andrecord keeping in a care settingD1 Evaluate the consequences ofnon-compliance with reference to themedia, service user safety and thecredibility of the care setting.P1 Describe the statutoryrequirements for reporting andrecord keeping in own caresetting.P2 Describe the regulatory andinspecting bodies’ requirementsfor reporting and record keepingin a care setting.M1 Analyse the implications ofnon-compliance with legislation,regulating and inspecting bodies’requirements.LO2 Explore the internal and external recording requirements in acare settingP3 Describe the process ofstoring of records in own caresetting.P4 Explain the reasons forsharing information withinown setting and with externalbodies.P5 Accurately illustrate theinternal and externalrequirements for recordinginformation in own caresetting.M2 Examine the current processesin own care setting related tostoring and sharing records.D2 Evaluate own work setting’sarrangements and processes forstoring and sharing information,making recommendations forimprovement.LO3 Review the use of technology in reporting and recording serviceuser care in a care settingD3 Evaluate the effectiveness ofthe use of technology in terms ofmeeting service user needs,ensuring appropriate care is givenand maintaining confidentialityP6 Describe how technology isused in recording and reportingin own care setting.M3 Review the use of digitaltechnology in relation to ownmedical management proceduresP7 Explain the benefits ofinvolving service users in recordkeeping processes.or care plan.LO4 Demonstrate how to keep and maintain records in owncare setting in line with national and local policies 9 | P a g eUNIT 17/AB/ SEPT P8 Produce accurate, legible,concise and coherent recordsregarding service user care fordifferent service users followingown setting’s guidelines.P9 Explain different aspects of ownmanagement of service userrecords with reference tocompliance with national and localpolicies and guidelines.M4 Analyse the process of maintainingrecords in own setting, identifying anypotential or actual difficulties.D4 Evaluate the effectiveness of owncompletion of documentation in terms ofmeeting service user needs, ensuringappropriate care is given and effectivereporting is carried out. 10 | P a gUNIT 17AB/ SEPT Academic Integrity (Note to avoid Plagiarism)Academic integrity is a fundamental expectation for all college/university students and while itis acknowledged that mitigating circumstances might be raised as factors in student behaviour,cheating cannot be disregarded. GBS definition of plagiarism, as contained in GBS AcademicGood Practice and Academic Misconduct Policy and Procedure, has been expanded to makeexplicit that copying from texts or web sources and copying work from other studentsconstitutes 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 sothat the person considering this work is given the impression that what they have before themis the student’s own original work when it is not. Plagiarism also occurs where a student’s ownwork is re-presented without being properly referenced. Plagiarism is a form of cheating and isa disciplinary offence.”Plagiarism is easy to avoid by making sure you reference all of the sources of material that youuse in the completion of your work. Pearson has developed Guidelines on HarvardReferencing which are available in Academic Support Area for Students on Moodle (VLE) aswell as on respective unit pages.If you are concerned about referencing techniques, please draw the matter to your UnitLecturer or Academic Support Team on academicsupport@globalbanking.ac.uk so that youmay receive extra advice.Group coursework may be designed so that the contribution of each student is identifiable butinclusion of plagiarised material is still the responsibility of the whole group. All members of thegroup should exercise vigilance to ensure that work is properly referenced; in group- work,students have a shared responsibility for the assignment. 17 | P a gUNIT 17/AB/ SEPTTextbooksLILLYMAN, 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 andAssistant Practitioners. Oxford: Wiley BlackwellReports and JournalsIPSOS MORI (2013) E-readiness in the social care sector for SCIE: Final report. Departmentof Health (2012) Digital Strategy: Leading the culture change in health and careScott B. (2004) Health record and communication practice standards for team based care.NHS Information Standards BoardWebsiteshcpc.org.uk Health and Care Professions CouncilHealth record and communication practicestandards for team based care. NHS InformationStandards Board, 2004.(Guidance)Recommended Resources
