Obtain supporting information to inform the assessment of an individual
Overview
This standard covers gathering information to support and inform the assessment of the health status and needs of an individual.
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 supporting information to inform the assessment of an individual
P2. provide support to the individual, ensuring that you respect their rights and wishes relating to their privacy, beliefs and dignity
P3. explain your role and the information you need
P4. check and confirm whether any relevant others acting as the source of information has the authority to:
• provide you with relevant information about the individual
• provide informed consent where the individual is unable to do so directly
P5. establish consent and access information on obtaining supporting information to inform the assessment of an individual
P6. obtain details of the individual's prior health status and circumstances over a sufficient period of time to inform assessment, in accordance with the individual's presenting symptoms
P7. use appropriate questions to explore, clarify and confirm any unusual or ambiguous information
P8. check and confirm that the information is reliable, current and relates to the individual
P9. support the assessment with as complete and accurate a picture of the individual as possible
P10. treat all information provided to you as confidential in accordance with organisational policy and practice
P11. complete all documentation required for obtaining supporting information to inform the assessment of an individual
Knowledge and Understanding
You need to know and understand:
K1. how to access and interpret all relevant work instructions, legislation, guidelines, policies, procedures and protocols needed to obtain supporting information to inform the assessment of an individual
K2. the scope and limitations of your own competence, responsibilities and accountability as it applies to your job role
K3. specific procedures for reporting issues which are beyond your competence, responsibilities and accountability
K4. the principles, practice and procedures associated with informed consent
K5. the needs of individuals including issues relating to dignity, confidentiality, and privacy
K6. what evidence you should seek to demonstrate a third party's ability and authority to provide information about an individual
K7. the ways an individual's belief system can influence their willingness to share personal information with you or others and why it is important that you respect these views
K8. the reasons why your role and responsibilities should always be explained when taking information
K9. the information that needs to be gathered and why this is necessary
K10. why information needs to be gathered over a sufficient period of time and how this might vary from context to context
K11. 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
K12. what sort of information it would be important to capture about the circumstances leading up to an individual requiring medical assistance
K13. how to complete and safely store all relevant documentation in accordance with organisational requirements