1.1 Identify own roles and responsibilities with regard to the current legislation, national guidelines, policies, protocols and good practice guidelines when obtaining an individual’s history
There are several specific pieces of legislation and guidelines that healthcare and social care professionals must be aware of when obtaining an individual’s history:
Data Protection Act 2018: The Data Protection Act (DPA) sets out the rules for protecting personal data, including medical information. Under the DPA, individuals have the right to be informed about how their personal data will be used and to have their personal data processed fairly and lawfully. Healthcare and social care professionals must ensure that they are complying with the DPA when obtaining and using an individual’s history.
National Guidelines: There are various national guidelines that healthcare and social care professionals should follow when obtaining an individual’s history. For example, the National Institute for Health and Care Excellence (NICE) provides guidelines on various aspects of healthcare, including how to obtain and record an individual’s history.
Code of Practice: The Code of Practice is a set of guidelines that healthcare and social care professionals must follow in order to meet the standards of their professional bodies. For example, the Health and Care Professions Council (HCPC) has a Code of Practice that sets out the standards practiioners must follow when obtaining and using an individual’s medical history.
It is important for healthcare and social care professionals to be familiar with these pieces of legislation and guidelines and to follow them when obtaining an individual’s history in order to protect the individual’s personal data and ensure that their rights are upheld. As a healthcare or social care professional, it is important to understand and adhere to the current legislation, national guidelines, policies, protocols, and good practice guidelines when obtaining an individual’s history. This includes the following roles and responsibilities:
Obtain informed consent: Before obtaining an individual’s history, it is crucial to obtain their informed consent. This means that the individual must fully understand and agree to the purpose of obtaining their history and how it will be used. Informed consent should be obtained in writing, and the individual should be given the opportunity to ask questions and raise any concerns.
Protect personal information: An individual’s personal and medical information is confidential and should be treated with the utmost respect. It is the responsibility of the healthcare or social care professional to ensure that all personal information is kept secure and only shared with those who have a legitimate need to know.
Follow national guidelines and protocols: It is important to follow the national guidelines and protocols that have been established for obtaining an individual’s history. This may include following specific procedures for obtaining and recording the history, as well as adhering to guidelines on how the information can be used and shared.
Use appropriate language: When obtaining an individual’s history, it is important to use language that is respectful, inclusive, and appropriate for the individual’s age, culture, and language preferences.
Be respectful and sensitive: It is important to be respectful and sensitive when obtaining an individual’s history, particularly if the individual is vulnerable or has experienced trauma. This may include being mindful of the individual’s emotional state, using supportive language, and being patient and understanding.
In summary, as a healthcare or social care professional, it is my responsibility to follow the current legislation, guidelines, policies, and protocols when obtaining an individual’s history and to do so in a way that is respectful, sensitive, and compliant with the individual’s rights and preferences.
1.2 Explain the guidelines to be followed if the individual is unable to provide a relevant history
It can be difficult for the health and social worker when an individual is unable to provide relevant history. This could be due to various factors, such as language barriers, memory impairment, or a disability that prevents communication. Regardless of the reason why they are unable to provide information regarding their history, there are specific guidelines which must be followed by the health and social worker in order to ensure that all parties involved receive equitable care.
Firstly, when working with someone unable to communicate effectively regarding their medical or social needs, it is important for practitioners to assess them holistically by considering other forms of assessment, such as observational techniques or interviewing family members if applicable. Observation techniques should consider physical and psychological characteristics displayed by individuals during interactions with others, whereas interviewing family members entails carefully crafting questions that allow information about an individual’s background to be gleaned from secondary sources such as birth certificates or school reports, etc. By employing these methods alongside traditional health/social work assessment tools (e.g., biographical questionnaires), clinicians have greater insight into a patient’s background, enabling them to craft more personalised treatment strategies tailored towards meeting each client’s unique requirements.
Once comprehensive assessments have been completed where possible current support networks should then be identified and involved in the planning of services and interventions. This is key as family members, carers, or advocates are likely to have knowledge that can be essential for addressing complex health or social issues which may have led to the individual’s situation (e.g. substance misuse etc.). Where access to these individuals is impossible, then appropriate referrals should be made so that external help and advice can be provided in order for health practitioners to form an accurate picture of their life before treatment commences.
Finally, wherever possible, patients themselves should also remain informed about all stages of assessment as well as any decisions made regarding their care. Although this presents a unique challenge when dealing with someone unable to communicate effectively (due to difficulty understanding language/ideas), it is nonetheless vital to adopt strategies such as visual aids like pictures where practicable alongside other forms of communication, including sign language if applicable, so they understand what’s being discussed by healthcare professionals concerning them. By doing this, individuals who cannot express themselves directly are less likely to feel confused or excluded during the process, ultimately promoting better health outcomes.
In conclusion, when working with someone who cannot provide a relevant history, it’s important for practitioners to remember that holistic assessments are essential alongside engaging current support networks and the patient wherever possible. By following these guidelines health, social workers can ensure equitable care is provided to all parties involved.
1.3 Explain how to check a third party’s authority and ability to provide information about an individual
In a health and social care setting, it is essential to verify a third party’s authority and ability to provide information about an individual in order to protect the individual’s privacy and ensure that their rights are upheld. To check a third party’s authority and ability to provide information, the following steps should be followed:
Determine the purpose of obtaining the information: Before checking a third party’s authority and ability to provide information, it is important to determine the purpose of obtaining the information. This will help to ensure that the information is relevant and necessary and that it will be used in a way that is consistent with the individual’s best interests.
Obtain consent from the individual: If the individual can give their own consent, it is important to obtain their consent before obtaining information from a third party. This ensures that the individual is aware of the purpose of obtaining the information and how it will be used and that they have the opportunity to ask questions and raise any concerns.
Verify the third party’s identity: It is important to verify the third party’s identity to ensure that they are whom they claim to be. This may involve checking identification documents or asking for additional information that only the third party would know.
Determine the third party’s relationship to the individual: It is important to determine the third party’s relationship to the individual in order to understand the nature of their authority to provide information. For example, a family member may have a greater level of authority to provide information than a friend or co-worker.
Assess the third party’s credibility: It is important to assess the third party’s credibility in order to determine whether their information is reliable. This may involve considering their knowledge of the individual and their history, their ability to provide specific details, and their motivation for providing the information.
Follow relevant policies and procedures: It is important to follow the relevant policies and procedures when obtaining information from a third party, as these will outline the steps that should be taken to ensure that the information is obtained in a way that is compliant with the individual’s rights and preferences.
Respect the individual’s privacy: It is important to respect the individual’s privacy and to only obtain information that is necessary and relevant to their care.
Document the information obtained: It is important to document the information obtained from a third party in order to have a record of the information and to ensure that it is used appropriately.
Consider the individual’s cultural and linguistic needs: If the individual has specific cultural or linguistic needs, it may be necessary to take these into consideration when obtaining information from a third party. For example, an interpreter may be needed if the third party does not speak the individual’s primary language.
Seek guidance from colleagues or supervisors: If you are unsure about how to proceed when obtaining information from a third party, it may be helpful to seek guidance from colleagues or supervisors who have more experience in this area.
1.4 Outline the steps to be taken to clarify and confirm any missing or ambiguous information in an individual’s history
To ensure that a patient receives the best care possible in a health and social care setting, it is crucial to clarify and confirm any unclear or missing information in the patient’s history. The actions listed below should be taken to confirm and elucidate any unclear or missing information:
Determine the facts that are unclear or missing: Identifying the information that is lacking or ambiguous is the first step in confirming and clarifying it. This might entail looking over the person’s medical history or getting information directly from the person or their family.
Identify the significance of the unclear or missing information: Once the ambiguous or missing information has been located, it is crucial to assess its significance in light of the patient’s care. Prioritising the confirmation and clarification of some information may be necessary because it may be more important for the individual’s treatment or care plan than other information.
Obtain more details from relevant sources: It might be necessary to look for additional information from relevant sources in order to clarify and confirm the information if the missing or ambiguous information is crucial to the individual’s care. The individual’s medical records may be reviewed, other healthcare or social service professionals may be consulted, and family members or other caregivers may be contacted.
Utilise effective communication methods: To ensure that additional information is obtained in a way that is respectful, sensitive, and in compliance with the individual’s rights and preferences, it is crucial to use the right communication techniques when asking for it from relevant sources. This may involve using language that is suitable for the individual’s age, culture, and language preferences, as well as being aware of the individual’s emotional state.
Record the extra information you learned: To keep track of the information and make sure it is appropriately used, it is crucial to document the additional information acquired. In order to do this, the person’s medical records may need to be updated, or a new record may need to be made specifically for the new information.
Review and make changes to the person’s care plan: It might be necessary to review and revise the person’s care plan in light of the new information once the unclear or missing information has been confirmed and clarified. This could mean making changes to the person’s treatment plan, medications, or other aspects of their care as needed.
1.5 Explain own role and responsibilities in line with obtaining a client history
As a health and social care professional, it is my responsibility to obtain an accurate client history from each client I work with. This includes taking the time to understand their individual circumstances, as well as gathering information on past experiences which could be contributing to their current situation. To do this effectively, I need to build trust and rapport with my clients so that they feel comfortable sharing detailed information about themselves.
Furthermore, it is also essential for me to maintain confidentiality throughout the process in order for them to feel safe and respected when speaking about sensitive topics. I must keep thorough notes of our conversations in order to ensure accuracy during any assessments or treatments made later down the line – all while working within relevant laws surrounding data protection, such as GDPR guidelines.
Obtaining a comprehensive client history allows me to provide more informed support explicitly tailored towards the individual needs of each person who accesses care services through us, ultimately allowing them better opportunities leading towards achieving positive outcomes overall. My responsibilities in this regard require me to be professional, ethical and approachable for my clients to open up about their life experiences, as well as be non-judgmental at all times.
REFERENCE
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Doyle, G. R., & McCutcheon, J. A. (n.d.). 2.4 Health History – Clinical Procedures for Safer Patient Care. 2.4 Health History – Clinical Procedures for Safer Patient Care. Retrieved December 20, 2022, from https://opentextbc.ca/clinicalskills/chapter/2-4-health-history-subjective-assessment/
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