Obtain case history
Overview
This standard covers gathering information to obtain a relevant history from the individual and where appropriate a relevant other 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 communicate effectively to meet individuals' needs and wishes and work in line with health and safety legislation, policy and practices.
Performance criteria
You must be able to:
P1. identify and agree the roles and responsibilities of yourself and others in obtaining case history
P2. confirm identity of the individual in accordance with organisational procedures
P3. establish consent and access information on obtaining case history
P4. explain your role and responsibilities and the purpose of obtaining an individual's relevant history
P5. respect the individual's privacy, dignity, wishes and beliefs and maintain the confidentiality of the information obtained in line with legislation and organisational requirements
P6. 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
P7. explore, clarify and confirm any unusual or ambiguous information and record the information clearly and accurately
P8. complete all relevant documentation required for obtaining case history
Knowledge and Understanding
You need to know and understand:
K1. the current legislation, guidelines, policies, procedures and protocols which are relevant to your work practice and to which you must adhere
K2. the scope and limitations of your own competence, responsibilities and accountability as it applies to your job role
K3. how to access and interpret all relevant work instructions and information
K4. specific procedures for reporting issues which are beyond your competence, responsibilities and accountability
K5. the principles, practice and procedures associated with informed consent
K6. how to obtain confirmation of an individual's identity in accordance with organisational procedures
K7. the needs of individuals including issues relating to dignity, confidentiality, and privacy
K8. the need to confirm your role and responsibilities and the individual's identification prior to obtaining a relevant history
K9. the steps you would take to ensure that ethical, cultural and confidentiality requirements are maintained when taking an individual's history in line with legislation and organisational requirements
K10. the steps you would take to try to clarify and confirm any information which is ambiguous or missing from an individual's or relevant other's narrative
K11. the types of information that need to be gathered and why each is necessary
K12. what information would be important to capture about the circumstances leading up to an individual requiring health care
K13. the impact of comorbidity
K14. how to complete and safely store all relevant documentation in accordance with organisational requirements