Back

Obtain supporting information to inform the assessment of an individual

URN: SFHEUSC02
Business Sectors (Suites): Emergency, Urgent and Scheduled Care,Emergency, Urgent and Scheduled Care.
Developed by: Skills for Health
Approved on: 2021

Overview

This standard covers gathering information to support and inform the assessment of the health status and needs of an individual requiring medical assistance.

Performance criteria

You must be able to:

  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 relevant others 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. provide support to the individual and carers and ensure health and safety measures are implemented at all times
  8. explain your role and the info you need

  9. 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

  10. obtain informed consent from any relevant others acting as the source of information, where appropriate, to share the information they provide

  11. 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
  12. use appropriate questions to explore, clarify and confirm any unusual or ambiguous information
  13. check and confirm that the information is reliable, current and relates to the individual
  14. support the assessment with as complete and accurate a picture of the individual as possible
  15. treat all information* *provided to you as confidential in accordance with organisational policy and practice
  16. complete and store all relevant documentation in accordance with organisational requirements

Knowledge and Understanding

You need to know and understand:

  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. the needs of individuals and carers including issues relating to dignity, confidentiality, and privacy
  11. organisational management structures, roles, and responsibilities
  12. the procedures and methods relating to the coordination of inter-disciplinary and multi-disciplinary teams within and across services
  13. what evidence you should seek to demonstrate a third party's ability and authority to provide information about an individual in need of medical assistance
  14. 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
  15. the reasons why your role and responsibilities should always be explained when taking information
  16. the information that needs to be gathered and why this is necessary
  17. why information needs to be gathered over a sufficient period of time and how this might vary from context to context
  18. 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
  19. what sort of information it would be important to capture about the circumstances leading up to an individual requiring immediate medical assistance
  20. how to complete and safely store all relevant documentation in accordance with organisational requirements

Scope/range

Scope Performance

Scope Knowledge

Values

Behaviours

Skills

Glossary

Links To Other NOS

External Links

Version Number

2

Indicative Review Date

2026

Validity

Current

Status

Original

Originating Organisation

Skills for Health

Original URN

SFHEUSC02

Relevant Occupations

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

SOC Code

2259

Keywords

Information; obtain, individual; assessment