CM A1 Obtain information to inform the assessment of an individual

Overview

This standard covers performing a comprehensive history and physical examination to develop a plan of pro-active care, including end of life care. Pro-active care involves monitoring for changing clinical signs, responding to and carrying out treatments during exacerbation of illness in accordance with the individual’s baseline assessment, current health status and the disease processes. This standard is relevant to those who provide proactive and co-ordinated Case Management. Here, Case Management means identifying and risk stratifying vulnerable, high-risk people with complex multiple long term conditions. Case Management should take place within the philosophy of enabling and promoting self care, self management and independence. Users of this standard will need to ensure that practice reflects up to date information and policies. Version No 1

Knowledge and Understanding

You will need to know and understand:

1. the reasons why your role and responsibilities should always be explained when taking information
2. the types of information that need to be gathered and why each is necessary
3. clinical norms with regard to different groups of individuals and presenting symptoms for commonly experienced long term conditions
4. mental health assessment and utilising appropriate assessment tools
5. how communication style may be modified to ensure it is appropriate to the individual’s level of understanding, culture and background, preferred ways of communicating and needs
6. what sort of obstacles to communication can arise and the actions to be taken to manage them in a constructive manner
7. why information needs to be gathered over a sufficient period of time and how this might vary from context to context
8. why it is important to establish informed consent to the sharing of information, where the individual or third party is able to provide this, and what steps can be taken when this is not provided
9. what evidence you should seek to demonstrate a third party’s ability and authority to provide information about an individual in need of medical assistance
10. the steps you would take to try to clarify and confirm any information which is ambiguous or missing from an individual’s or third party’s narrative
11. what sort of information it would be important to capture about the circumstances leading up to an individual requiring immediate medical assistance
12. the importance of recording information clearly, accurately and in a systematic manner
13. the steps you would take to ensure that the privacy, dignity, wishes and beliefs of the individual are maintained
14. the ways an individual’s belief system can influence their willingness to share personal information with you or others and why it is important that you respect these views
15. the organisational policy and practices with regard to the confidentiality of information
16. the legislation (National and European) relating to the work being undertaken, the context in which it takes place and the individuals with whom one works; codes of good practice which support the implementation of legislation (such as the Data Protection Act); how to interpret and apply relevant legislation to the work being undertaken.

Performance Criteria

You must be able to do the following:

1. explain clearly:
1. your role and responsibilities
2. what information you need
3. the reasons why you need the information
4. with whom the information will be shared
2. obtain the informed consent of the person for the actions undertaken and agree the information which may be passed to others
3. obtain details of the individual’s prior health status and circumstances over a sufficient period of time to inform assessment, in accordance with the individual’s current situation
4. use appropriate questions to explore, clarify and confirm any unusual or ambiguous information
5. record the information clearly and accurately in a systematic and logical manner that clearly shows the history of the individual’s condition
6. respect the individual’s privacy, dignity, wishes and beliefs
7. treat all information provided to you as confidential in accordance with organisational policy and practice
8. communicate with people in a manner which:
1. is consistent with their level of understanding, culture, background and preferred  ways of communicating
2. acknowledges the purpose of the communication
3. is appropriate to the context
4. encourages their participation
5. responds to communications of any kind from them
9. constructively manage any obstacles to communication
10. ensure your safety as appropriate to the situation.
11. explain clearly:
1. your role and responsibilities
2. what information you need
3. the reasons why you need the information
4. with whom the information will be shared
12. check and confirm that the third party is able to provide you with relevant information
13. check and confirm whether the third party has the authority to:
1. provide you with information about the individual
2. provide informed consent where the individual is unable to do so directly
14. obtain informed consent from the third party, where appropriate, to share the information they provide about the individual requiring assessment
15. obtain details of the individual’s prior health status and circumstances over a sufficient period of time to inform assessment, in accordance with the individual’s current situation
16. use appropriate questions to explore, clarify and confirm any unusual or ambiguous information
17. record the information clearly and accurately in a systematic and logical manner that clearly shows the history of the individual’s condition
18. respect the individual’s privacy, dignity, wishes and beliefs in your interactions with the third party
19. treat all information provided to you as confidential in accordance with organisational policy and practice
20. communicate with people in a manner which:
1. is consistent with their level of understanding, culture, background and preferred ways of communicating
2. acknowledges the purpose of the communication
3. is appropriate to the context
4. encourages their participation
5. responds to communications of any kind from them
21. constructively manage any obstacles to communication
22. ensure your safety as appropriate to the situation.
23. explain clearly to any other party holding collateral information:
1. your role and responsibilities
2. what collateral information you need
3. the reasons why you need the collateral information
4. with whom the collateral information will be shared
24. check and confirm that the collateral information is reliable, current and relates to the individual concerned
25. use appropriate questions to explore, clarify and confirm any unusual or ambiguous aspects of the collateral information provided
26. ensure the assessment is based on as complete and accurate a picture of the individual as possible
27. record accurate and clear details of the source from which the collateral information was obtained
28. record the collateral information clearly and accurately
29. treat all collateral information provided to you as confidential in line with organisational policy and practice.

 

Additional Information

This National Occupational Standard was developed by Skills for Health. This standard links with the following dimension within the NHS Knowledge and Skills Framework (October 2004): Dimension: HWB6 Assessment and treatment planning