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

 Submission Front Sheet

Effective Reporting and Record-keeping in Health and Social Care Services (Unit 17)

Key Dates

Particulars	Key Dates
Semester starts	13/01/2025
Semester ends	04/04/2025
Formative assessment Dropbox opens	17/02/2025
Formative assessment Dropbox closes	09/03/2025
Final SUBMISSION box opens on	10/03/2025
Final SUBMISSION box closes on	06/04/2025 Sunday @ 23.59 pm
Summative Feedback will be given on	25/04/2025
Referral Dropbox will open from	07/04/2025
Referral Dropbox closes on	24/05/2025
Referral result declared	Ongoing within 2 weeks of submission

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.

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 (LOs)

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.

Any work submitted should include evidence of your research with references (Harvard Referencing).

Assignment Title: The use of reporting and record-keeping in ensuring safe and healthy environments for care

Submission Format: Essay

This submission will be in the form of an essay which is made up of two parts and submitted using a WORD processed document. PDF and other types of files are not accepted. The recommended length of this submission is 5000 words, although you will not be penalised for exceeding 5000 words. Where appropriate, learning theory and additional research must be used, and referenced according to the Harvard Referencing System. The work must include a bibliography or reference list for all referenced work using the Harvard Referencing System.

 

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. LO4 Demonstrate how to keep and maintain records in a care setting in line with national and local policies and appropriate legislation.

 

Assignment Brief and Guidance

Scenario 1: (If you are a healthcare professional use your own organisation) As a manager in ABC care home, you had recent visit from the CQC, and they reported that your relevant reports were up to date. However, a friend who happened to be a manager in another care home have had CQC visit, and failings were found in the areas of record keeping and reporting such as inaccurate medical records. Also, fire safety records were not updated, and incidents were not reported either correctly in line with RIDDOR (Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013) or not reported at all. Moreover, service users’ data were not properly secured in line with The Data Protection Act 2018 (GDPR 2018). As a result of these breaches, your friend has approached you to share some good practices with him to ensure that his care home was able to put their records in order to avoid closure of the care home. Activity 1- To support your friend effectively, you need to evaluate the consequences of non-compliance with reference to media, service user safety and the credibility of the care setting. Make sure to analyse them first. For an effective evaluation and analysis, you must include a comprehensive description of the statutory as well as regulatory and inspecting bodies’ requirements for reporting and record keeping in own care setting. Scenario 2: (For this part, please use your own organisation) The care home where you work as an operations manager has invited an external trainer to come and train you and your team on the use of latest technology in reporting and recording information i.e. in line with the immediate development of emerging technology so that your team will continue to keep up to date with current trends in the sector. After the training, your directors have asked you to provide same training to new staff members. In the training session you will need to show some examples of some of the records you have kept in the organisation, how you have completed, processed and preserved those records and data in line with the organisational policy as well as local and national policies and guidelines. Note: For those already working in a health and social care organisation, you are strongly advised to use examples related to your own daily practice. Activity 2- Based on the above scenario, you need to evaluate and examine the arrangements and processes for storing records, sharing information and the internal and external requirements for recording information within your own place of work making recommendations for improvement. To support your evaluation, with reference to own care setting, you also need to explain the reasons for sharing information within own setting and with external bodies. This should be followed by reviewing the use of digital technology and evaluating its effectiveness in terms of meeting service user needs, ensuring appropriate care is given and maintaining confidentiality when recording and reporting in relation to own medical management procedures or care plan. You should also explain the benefits of involving service users in record keeping processes. Finally, you will need to produce accurate, legible, concise and coherent records regarding service user care for different service users following own setting’s guidelines and then evaluate their effectiveness in terms of meeting service user needs, ensuring appropriate care is given and effective reporting is carried out. You will have to analyse as well, the different aspects (processes) of own management (maintenance) of service user records with reference to compliance with national and local policies and guidelines, identifying any potential or actual difficulties

 

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 car 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

Grading Details

Achievement of a Pass grade

A student must have satisfied all the Pass criteria for the learning outcomes, showing coverage of the unit content and therefore attainment at Level 4 or 5 of the national framework.

Achievement of a Merit grade

A student must have satisfied all the Merit criteria (as well as the Pass criteria) through high performance in each learning outcome.

Achievement of a Distinction grade

A student must have satisfied all the Distinction criteria (as well as the Pass and Merit criteria), and these define outstanding performance across the unit as a whole.

ALL GRADES ARE PROVISIONAL UNTIL INTERNALLY VERIFIED AND UNTIL EXTERNALLY CERTIFIED BY EDEXCEL.

THIS MEANS THAT A GRADE CAN BE CHANGED AT ANY POINT UNTIL EDEXCEL CERTIFIES IT

As per Pearson policy, you are only allowed two submissions per module. One for final submission and another one for referral. Failure to achieve a grade pass after a second submission will result in you having to repeat the module in the next term.

Any re-submission or late submission (unless authorised due to mitigating circumstances) will be capped at a PASS grade only.

• Present your work in one report style which should include a cover page, table of contents, introduction, conclusion, reference list, foot or end notes and appendices, if any.
• Include the reference code of this assignment on your assignment submission front page.
• Sign the Learner’s Statement of authenticity in the cover page. Failure to do so will result in the submission being declined.
• Ensure the following information is in the footer on every page:
• Your name
• The production date of your submission
• The code number of your assignment brief
• The page number (Each page must be numbered at the bottom right-hand side)
• Spell-check the document and make sure there are no grammatical errors as it may result in the submission being declined.
• Complete all the tasks in a Holistic manner as set in the brief and without separating the assessment criteria to avoid a potential referral.
• Create your own titles and sub-headings to structure the work without copying the assessment criteria verbatim.
• Produce clear specific reasoning and arguments in support of your answers.
• Submit your work in a single WORD processed document of not more than 5000 words for all learning Outcomes. This word limit is only for guidelines and is not applied to grading. PDF and other types of files are not accepted.
• You must include a bibliography at the end to show where your information was sourced. Failure to do so may result in the submission being declined
• Your sources must be identified using the Harvard referencing system. The words used in your bibliography will not be included in your word count.
• You must use Arial, size 12, 1.5 line spacing and black to format the text.

To access any feedback (formative/summative) you will have to access Moodle and open your assignment. You will have to click on the blue comment box in the righthand side and the feedback will appear within the text. You might have to click on the blue bubbles to see the feedback.

Extension and Late Submission

If an extension is necessary for a valid reason, requests must be made in writing using a course work extension request form to the head of department. Please note that the lecturers do not have the authority to extend the coursework deadlines and therefore do not ask them to award a coursework extension.

The completed form must be accompanied by evidence such as a medical certificate in the event of you being sick.

Plagiarism and Collusion

Any act of plagiarism and collusion will be seriously dealt with according to the regulations and MRC Malpractice policy

Plagiarism occurs when a student misrepresents any work submitted as his/her own work, the work of any other person or of any institution. Examples of forms of plagiarism include:

• the verbatim (word for word) copying of another’s work without appropriate and correctly presented acknowledgement.
• the close paraphrasing of another’s work by simply changing a few words or altering the order of presentation, without appropriate and correctly presented acknowledgement.
• unacknowledged quotation of phrases from another’s work;
• The deliberate and detailed presentation of another’s concept as one’s own.

All types of work submitted by students are covered by this definition, including, written work, diagrams, designs, engineering drawings and pictures.

Collusion occurs when, unless with official approval (e.g., in the case of group projects), two or more students consciously collaborate in the preparation and production of work which is ultimately submitted by each in an identical, or substantially similar, form and/or is represented by each to be the product of his or her individual efforts.

All submissions for assessment must be submitted on Moodle to generate a Turnitin Report on similarity to detect potential plagiarism and collusion.

The maximum Turnitin score admissible is 15% but a submission can be classified as plagiarism and/or collusion with a lower score depending on the size of the submission and size of the text highlighted.

Assignments with plagiarism/ad or collusion will be automatically referred for reworking and resubmission. Please check the MRC Assessment policy as well as MRC Malpractice policy for details of the potential penalties as a procedure.

Including pictures of text (apart from the cover page or table of content) or pictures of any other type of information (diagram for example) without a citation and a Harvard Reference could be deemed to be an attempt of malpractice and could trigger an automatic referral as well as a malpractice procedure.

Any student might be called to seat through a viva with the lecturer to confirm any parts of the submission through an interview which will then form part of the summative assessment.

Using Artificial Intelligence

AI tools have proliferated and become more common and as a result, their usage for research has increased which prompted change of government policies in this matter.

Overall, it remains too easy for students to misunderstand how they can use Generative Artificial Intelligence tools and unintentionally breach academic integrity guidelines.

Research of information and the writing of academic work must always be performed by the student, and while it is acceptable to use an AI tool to start a research process, it is not allowed to use it to write a submission in your place.

The important part is to understand that the best way to produce a work is to research it through traditional methods (books articles, websites, journals).

Yet, AI tools could be used to help with the research but only as a starting point. Having found information, thanks to an AI tool, about a topic you are writing about, you should then research it using these traditional methods and include the references and citations based on these resources in your work.

Once you have the correct information, you need to write the assignment yourself, using an AI tool to do this for you is never allowed. The usage of paraphrasing tools might be appropriate to find alternative to some words and short sentences, but not or a whole paragraph/page/ work.

The same way Mont Rose College is using a similarity detection system, an AI detection tool is embedded in our systems and every submission you make will go through both of them.

Submissions for assessment that consist of large substantially unmodified output from Artificial Intelligence software may be considered as a very poor academic practice as it does not represent the student’s own work.

To this effect, the limit on AI detection has been set at 50%. If a submission is over that allowance, the submission could be rejected and awarded a Referral and/or the student called to seat through a viva with the lecturer to confirm any parts of the submission through an interview which will then form part of the summative assessment.

In cases where an individual persistently exhibits poor academic practice through inappropriate use of Artificial Intelligence tools, such as a lack of evidencing their use of the tools, they may be referred to the academic misconduct procedures and the range of the potential penalties.

Recommended Resources

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 Blackwel

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