CHS168 Obtain a patient/client history

Overview

This standard covers gathering information to obtain a relevant history from the individual and where appropriate a third party to establish the health status and needs of the individual to support and inform their assessment, intervention, care or treatment plan  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. work within your own level of competence, authority and knowledge base
2. the need to confirm your role and responsibilities and the individual’s identification prior to obtaining a relevant history
3. how to obtain the individual’s identity and information from a third party where an individual is unable to participate themselves and/or where there are communication difficulties
4. what evidence you should seek to demonstrate a third party’s ability and authority to provide information about an individual
5. how to report any unexpected, inconsistent or untoward information or evidence and the appropriate protocols, procedures and communication channels for doing so
6. how to communicate effectively in the appropriate medium to meet the individual’s or relevant other’s needs and preferences
7. the steps you would take to ensure that ethical, cultural and confidentiality are maintained when taking an individual’s history in line with legislation and organisational requirements
8. 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
9. the types of information that need to be gathered and why each is necessary
10. what information would be important to capture about the circumstances leading up to an individual requiring immediate medical assistance
11. the importance of recording information clearly, accurately and in a systematic manner in accordance with legislation and organisational requirements
12. the current national legislation, guidelines, and local policies and protocols which affect your work practice
13. the policies and guidance that clarify your scope of practice, accountabilities and the working relationship between yourself and others

Performance Criteria

You must be able to do the following:

1. explain your role and responsibilities and check the individual’s identity according to local guidelines before the taking of an individual’s history relevant to your work area
2. follow national and local guidelines if the individual is unable to provide a relevant history
3. communicate effectively in the appropriate medium to meet the individual’s or third party’s needs and preferences
4. check the individual’s or third party understanding of the purpose of obtaining an individuals relevant history 
5. respect the individual’s privacy, dignity, wishes and beliefs and maintain the confidentiality of the information obtained in line with legislation and organisational requirements
6. obtain details of the individual’s prior health status and circumstances over a sufficient period of time to inform the assessment and requirements for your work    activities
7. use appropriate questions to explore, clarify and confirm any unusual or ambiguous information and record the information clearly and accurately in a systematic manner
8. accurately answer any questions at a level and pace that is appropriate to the individual’s or third party needs
9. maintain full, accurate and legible records of information collected in line with current legislation, guidelines, local polices and protocol

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: HWB2 Assessment and care planning to meet people’s health and wellbeing needs