Obtain case history

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.

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1. access and accurately interpret all relevant work instructions and information
2. work safely at all times and in accordance with all relevant legislation, guidelines, policies, procedures and protocols
3. deal promptly and effectively with any problems within your control and report those which cannot be solved
4. identify and minimise hazards and risk in the workplace
5. communicate with the individual and key people at a pace, in a manner and at a level appropriate to the individual's understanding, preferences and needs
6. respect the individual's rights and wishes relating to their privacy, beliefs, and dignity
7. confirm identity of the individual in accordance with organisational procedures
8. gain valid, informed consent from the individual in accordance with specific procedures
9. explain your role and responsibilities and the purpose of obtaining an individual's relevant history 
10. respect the individual's privacy, dignity, wishes and beliefs and maintain the confidentiality of the information obtained in line with legislation and organisational requirements
11. 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
12. use appropriate questions to explore, clarify and confirm any unusual or ambiguous information and record the information clearly and accurately
13. complete and store all relevant documentation in accordance with organisational requirements

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1. the current legislation, guidelines, policies, procedures and protocols which are relevant to your work practice and to which you must adhere
2. the scope and limitations of your own competence, responsibilities and accountability as it applies to your job role
3. how to access and interpret all relevant work instructions and information
4. specific procedures for reporting issues which are beyond your competence, responsibilities and accountability
5. the duty to report any acts or omissions that could be unsafe/detrimental to you or others
6. the hazards and risks which may arise during the execution of your work role and how you can minimise these
7. how to adapt communication styles in ways which are appropriate to the needs of the individual  
8. the correct use of any equipment and PPE to protect the health and safety of you and others
9. the principles, practice and procedures associated with informed consent
10. how to obtain positive confirmation of an individual's identity in accordance with organisational procedures
11. the needs of individuals including issues relating to dignity, confidentiality, and privacy
12. organisational management structures, roles, and responsibilities
13. the need to confirm your role and responsibilities and the individual's identification prior to obtaining a relevant history
14. 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
15. 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
16. the types of information that need to be gathered and why each is necessary
17. what information would be important to capture about the circumstances leading up to an individual requiring immediate medical assistance
18. the impact of comorbidity 
19. how to complete and safely store all relevant documentation in accordance with organisational requirements

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2

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2026

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Current

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Original

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Skills for Health

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SFHCHS168

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Health and Social Care, Health and Social Services Officers, Health Associate Professionals, Health Professionals, Health, Public Services and Care, Healthcare and Related Personal Services

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2259

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Obtain, case, history

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