CHS40 Establish a diagnosis of an individual's health condition

Overview

This standard is about determining a diagnosis following initial assessment and investigations of an individual’s suspected health condition.  It involves reviewing the results of the initial assessment and initiating any further tests to confirm the diagnosis and the possible underlying causes. This is applicable to a wide range of health contexts and roles in both primary and secondary 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. your own level of competence, authority and knowledge in relation to undertaking a diagnosis of a individual’s health condition
2.  the importance of respecting individuals’ privacy, dignity, wishes and beliefs and how to do so
3. the importance and methods of obtaining valid consent and how to do so
4. the importance of obtaining full and accurate information about an individual’s and their family past medical history  and how to do so
5. how to interpret evidence from an individual’s history, baseline observations and tests, and further investigations in order to make a diagnosis of suspected health conditions
6. the importance of communicating with individuals and relevant carers in a manner that is consistent with their level of understanding, culture, background and preferred ways of communicating
7. the anatomy and physiology of the human body relevant to the individuals presenting health condition
8. the range of baseline and additional observations/ investigations that can be undertaken, how and when they are performed, their relevance to the diagnostic process
9. clinical examination skills and procedures appropriate to establishing a diagnosis of suspected health conditions
10. the difference between assessment and diagnosis
11. normal and abnormal results from investigations and their implications
12. the factors which determine the risk of specific health conditions and the relative impact of these factors
13. signs, symptoms and indications of the different stages of specific health conditions
14. conditions which may present with similar symptoms to suspected health conditions
15. short-, medium- and long term effects of specific health conditions on physical, psychological, mental and biological states and functions
16. the socio-economic and epidemiological factors affecting specific health conditions
17. the effects, side-effects and potential interactions of different drugs and their effect on the diagnostic process
18. the methods for establishing prognosis and the implication of different types of prognosis
19. how information concerning individuals should be recorded and stored in accordance with information governance
20. the information technology available to maintain registers and call and recall people for assessments to establish a diagnosis, and how to use it
21. the current European and National legislation, national guidelines, organisational policies and protocols and Clinical Governance which affect your work practice
22. your responsibilities and accountability in relation to the current European and National legislation, national guidelines and local policies and protocols and Clinical Governance

Performance Criteria

You must be able to do the following:

1. check the individuals identity and confirm valid consent has been obtained for the healthcare investigations or activities required to establish a diagnosis.
2. explain your own role, its scope, your responsibilities and accountabilities clearly to the individual and relevant carers
3. respect the individual’s privacy, dignity, wishes and beliefs at all times
4. communicate with the individual in an appropriate manner, recognising the stressful nature of a potential diagnosis
5. consider all the relevant evidence from the individual’s history, baseline observations and tests, and clinical examination
6. make use of clinical interpretations and reports to make justifiable assessment of the nature, likely causes and prognosis of the individual’s health condition in accordance with clinical governance
7. request further investigations, if required, following national, local and organisational guidelines and protocols
8. explain to the individual why you are requesting further investigations, if any, what can be expected to happen and the expected timescales to review the findings and possible implications of normal and abnormal results
9. provide opportunities for the individual to ask questions and increase their understanding of their condition
10. assess the need for support and provide reassurance where appropriate
11. discuss with colleagues, or seek advice from others who are able to assist, where the information you have gathered is difficult to interpret
12. discuss the diagnosis with the individual to enable them to think through the implications and how these can be managed
13. make a full, accurate and clear record of the information obtained used to establish the diagnosis
14. reassure the individual and relevant carers  and explain and confirm understanding for the next steps
15. ensure you maintain the confidentiality of information at all times in accordance with information governance

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