Develop, Maintain and Use Records and Reports

The Level 4 Diploma in Care unit ‘Develop, Maintain and Use Records and Reports‘ explores the legal and organisational requirements for securely handling confidential information and the use of records and reports for informing decisions. It also looks at the use of ICT for collecting, storing and sharing information.

It is made up of 3 learning outcomes and several assessment criteria.

1. Understand the legal and organisational requirements for recording information and providing reports
   • 1.1 Specify own responsibilities and those of others when recording information and producing reports
   • 1.2 Explain the legal requirements and agreed ways of working for the security and confidentiality of information.
2. Be able to prepare professional records and reports that meet legal requirements, and agreed ways of working
   • 2.1 Support individuals to participate in the preparation of reports
   • 2.2 Produce accurate and coherent records and reports that can be understood by those who have a right to see them
   • 2.3 Maintain accurate, complete, retrievable and up to date records
   • 2.4 Ensure that records and reports comply with legal and organisational requirements
   • 2.5 Explain how to balance the tension between confidentiality and openness in records and reports
   • 2.6 Use Information Communication Technology (ICT) systems for the collection and storage of information
   • 2.7 Use ICT that supports information exchange within and across disciplines and organisations.
3. Be able to use records and reports to inform judgements and decisions
   • 3.1 Clarify the accuracy of records and reports with individuals and others
   • 3.2 Respond to feedback from those who receive records and reports
   • 3.3 Demonstrate the use of facts and evidence-based opinions within records and reports
   • 3.4 Evaluate how own records and reports provide evidence for the basis of judgements and decisions.