CHS38 Plan assessment of an individual's health status

Overview

This standard covers planning and agreeing assessment. The practitioner needs to review referral information, and obtain and review any other relevant information. A decision has to be made, with the individual concerned, on the type of assessment procedure that is to be undertaken, and then steps taken to schedule the procedure. 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. local policies which affect your work practice in relation to working with individuals who require assessment
2. your responsibilities under the current European, national and local legislation and policies on your actions within the care environment
3. the ethics and responsibilities of practitioners, and relevant professional bodies, codes of conduct, and guidelines
4. evidence-based practice and its role in improving care
5. government and organisational policies relating to the provision of assessments in your area of practice
6. the national assessment framework for the client group with which you work
7. the referral process within the multi-disciplinary team
8. organisational criteria for prioritisation of referrals within your area of practice
9. national and local policies and guidelines relating to the management and effective use of assessment resources
10. organisational management structures, roles, and responsibilities
11. procedures, protocols, and pathways for liaising with individuals, carers, practitioners, departments, and agencies
12. the organisational policy and practices with regard to the keeping and sharing of clinical records, recording information and maintaining confidentiality
13. how to provide feedback on services
14. legislation and legal processes relating to consent
15. the principles of valid consent, including implied consent and expressed consent
16. the relevant national and organisational policies and guidelines on consent, including methods to be used to achieve consent where the individual is not able to give their informed consent
17. statutory statements, living wills, advanced directives, and other expressions of an individual’s wishes
18. the needs of individuals and carers, including issues relating to dignity, confidentiality, and privacy
19. the role, responsibilities, needs, and relationships between individuals and carers
20. the services and assistance that the individual and their carers should be entitled to
21. the type of information that is most useful to individuals and their carers, their rights to obtain it, and how they can access it
22. how individuals and carers respond to specific assessment procedures
23. aetiology, pathogenesis, and progress of conditions in your area of practice, including genetic or environmental factors
24. the anatomy, physiology, and pathology relevant to specific conditions
25. the methods for managing specific conditions
26. the short, medium, and long term effects of specific conditions on individuals and their carers
27. symptoms of specific conditions, and potential complications and outcomes
28. the methods for recognising and identifying symptoms of specific conditions
29. the way symptoms can interact with each other, and how they can mask or be indications of other conditions
30. the way co-morbidities affect assessment procedures and outcomes in your area of practice.
31. established and new assessment procedures and techniques in your area of practice
32. the equipment and accessories to be used with specific assessment procedures
33. the suitability of assessment procedures and techniques for specific groups of individuals
34. the risks and complications of specific assessment procedures and techniques
35. the guidelines and procedures for quality assurance, and evidence of effectiveness of specific assessment procedures
36. the methods to assess and monitor the individual during assessment procedures
37. the methods and procedures for referring individuals and for receiving referrals
38. the criteria and options for evaluating and prioritising referrals and other referral actions
39. the practitioners and agencies normally involved in referrals, and sources of information on them
40. the types of referral enquiries that are received, and procedures for clarifying information
41. sources of authoritative information on assessment procedures in your area of practice, including evidence based information
42. the centres of research and development on assessment procedures, and the current issues and research debates
43. information and educational resources for practitioners, individuals, and carers, and methods for accessing them
44. journals, magazines, web-sites, and patient guidance notes and leaflets for specific assessment procedures
45. voluntary organisations, charities, and interest groups relating to different conditions

Performance Criteria

You must be able to do the following:

1. respect the individual’s rights and wishes relating to their consent, privacy, beliefs, and dignity
2. provide support to the individual, and the carers they specify, to enable them to make informed choices throughout the agreement process
3. obtain and review all relevant referral information relating to the individual
4. determine the clinical objectives and priorities for the assessment of the individual’s health status
5. determine from the available information whether the individual is in an appropriate condition to undergo the assessment
6. establish any specific requirements of the individual which will need to be taken into account during the assessment from the available information
7. get the individual’s consent to obtain further information if the initial information is insufficient for effective prioritisation or assessment to take place
8. use research evidence, together with national and local guidelines and policies, to establish the tools and methodologies that will be used to assess the individual
9. select the assessment tools and methodologies which take account of the needs and goals of the individual and all other relevant factors
10. establish and confirm the roles and responsibilities of the practitioners who will be involved in the assessment
11. ensure that the appropriate practitioners are capable of undertaking the assessment as required
12. agree the purpose, nature and timing of the assessment with the individual and all relevant people, according to organisational procedures
13. agree with the individual and all relevant people the methods and timing for reviewing the outcomes and reports of the assessment
14. ensure that the scheduling of the assessment is appropriate to the clinical objectives and priorities, and takes account of the needs of the individual
15. keep accurate, legible, and complete records, and comply with all the relevant legal, professional, and organisational requirements and guidelines.

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 This standard has replaced HCS_AN2, HCS_CARD1 and HCS_N2