CHS118 Form a professional judgement of an individual's health condition

Overview

This standard relates to the formation of a professional judgement of an individual’s health condition based on a review of an individual’s presenting symptoms and clinical history. It includes the collection and analysis of relevant information that will inform and/or confirm the functional or clinical diagnosis and the presentation of proposals for further action.  This competence will be used in conjunction with others relating to making baseline observations and tests, preparing a patient history and consulting with others. 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 interpret and apply legislation to your own work
2. the required procedures for taking notes and recording judgements
3. national, local and organisational procedures for requesting investigative procedures
4. legislation regarding confidentiality and information sharing, the provision of services, the rights of the individual, protection issues, anti-discriminatory practice, informed consent, relevant mental health legislation and care programme approach
5. the tensions which may exist between an individual’s rights and the organisation’s responsibility to individuals
6. the importance of gaining consent from individuals who lack capacity to consent
7. circumstances when further investigations, including child protection procedures, can be carried out, in line with organisational and national protocols and guidelines.
8. your own level of competence, authority and knowledge in relation to making judgements on individual’s health conditions
9. circumstances when further investigations, including child protection procedures, can be carried out, in line with organisational and national protocols and guidelines.
10. your own level of competence, authority and knowledge in relation to making judgements on individual’s health conditions
11. the anatomy and physiology of the human body
12. the value and uses of different sources of information that assist with the formulation of professional judgements, functional diagnoses and clinical diagnoses of health status
13. the importance of a systematic and logical approach to information use and analysis, and the risks associated with making a premature judgement.
14. why it is important to ensure that all information is taken into account in reaching a judgement
15. the processes associated with forming a justifiable judgement of an individual’s health status
16. the steps to be taken when a satisfactory judgement cannot be formed
17. the importance of clear communication in clinical settings and the potential effects of individual’s psychological status on the information provided
18. the importance of communicating with individuals 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 communication of any kind from them
6. Manages their psychological state
19. the importance of maintaining confidentiality during communication, consistent with legislation and the employers’ policies
20. the importance of recording information clearly, accurately and legibly
21. the procedures for referral, admission, discharge and other relevant follow up action
22. how and from whom to seek additional support and advice in formulating a judgement
23. health problems which may present with similar symptoms and how to differentiate between them
24. the causes and contributing factors associated with conditions within your specialist area of care
25. the different investigative procedures within your specialism that can be applied to assist with a formulation of judgement
26. the baseline observations that can be used to formulate a judgement of an individual’s health status
27. the further investigations that may be required to assist with diagnosis
28. where further investigations can be conducted, who conducts them how to request them, the timescales involved and any associated contra-indications
29. national, local and organisational procedures for the formulation of judgement of individual’s health status

Performance Criteria

You must be able to do the following:

1. Explain your role and responsibilities in relation to the diagnostic process, including what records will be kept
2. Ensure that all relevant information is available to inform your judgement
3. Clarify and confirm with the appropriate people:
1. Any unclear, confounding or unusual aspects of the individual’s health symptoms, health status or general well-being
2. Any changes in the individual’s health status relative to the last recorded information
3. Any issues which may influence health status
4. Obtain the individual’s consent for any additional assessment or investigation procedures, explaining clearly why these are needed to clarify or confirm any aspects of the individual’s current health status
5. Ensure that any additional assessment and investigation procedures are undertaken and results made available with suitable degree of urgency
6. Develop an accurate and justifiable judgement of the individual’s health condition, noting the nature and severity of any symptoms presented or described
7. Balance any additional or unusual aspects identified against the overall presentation of the individual, taking account of current evidence-based best practice
8. Record any potential contra-indications or other risks associated with health care treatments that may be indicated as a result of your evaluation
9. Initiate relevant follow-up action promptly in line with your judgement of priorities to meet the individuals needs for treatment
10. Communicate with the individual and carer(s) where relevant in an appropriate manner, confirming their understanding of and agreement o the next steps and providing explanation and reassurance in respect of their concerns.
11. Maintain, full, accurate and legible records of information collected and make these available for future reference in line with organisational 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