CHD HO1 Establish the details of the individual needing care

Overview

This standard is about establishing the details of the individual needing care. 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. how to communicate with patients and carers in a sensitive and appropriate manner
2. how to ask questions, listen carefully and summarise back
3. the importance of establishing rapport, and how to do so
4. the principle of confidentiality and what information may be given to whom
5. the principle of informed consent, and how to obtain informed consent from individuals
6. organisation’s procedures on making notes
7. organisation’s policy on confidentiality

Performance Criteria

You must be able to do the following:

1. communicate in a sensitive and appropriate manner with the individual
2. confirm the individual’s and their GP’s name and address
3. obtain informed consent from the individual, in line with organisational policy, before starting to work with them
4. confirm with the individual any medications that have been prescribed, their dose and frequency
5. clearly and concisely record details of services and interventions provided
6. ask the individual to explain their current health condition and circumstances in their own words
7. obtain information from other people (eg family members, carer, friends, ambulance operators, any other person accompanying the individual) if the individual is unable to provide you with the required information
8. make full and concise notes of all information on the individual’s records

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: HWB5 Provision of care to meet health and wellbeing needs