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1 – Obtain a Client History

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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.

My role and responsibilities with regard to the current legislation, national guidelines, policies, protocols, and good practice guidelines when obtaining an individual’s history include respecting the individual’s right to confidentiality, being mindful of power imbalances that may exist between myself and the service user, keeping all communication professional while also creating a safe space for sharing personal information, and understanding any relevant data protection regulations, such as the Data Protection Act 2018, that need to be followed in order for me to obtain a person’s history accurately.

I must ensure that I act within my scope of practice at all times by effectively using my knowledge base when collecting information from clients. This involves staying up-to-date with legislation changes, such as The Care Act 2014, which affects how services are delivered to meet people’s care needs and promote their independence where possible. It is also important for me to stay familiarised with local guidance produced by organisations regarding safeguarding and duty of care.

I should also be mindful that there may be language barriers or physical disabilities that need to be taken into consideration when obtaining a person’s history. It is important to use non-discriminatory, respectful, and professional language when asking questions that allow the service user to explain their situation with minimal difficulty or feeling of intimidation in a suitable environment where they are comfortable sharing such sensitive information. This will help to build trust between us.

To ensure my practice meets national standards, I must remain compliant with guidelines set by The National Institute for Health and Care Excellence (NICE), which covers all areas from mental health issues to end-of-life care requirements, including how it relates to law and policy. This ensures that their wishes are respected at all times during our encounter, regardless of gender, race, or age, among other factors.

In conclusion, it is essential that I am aware of relevant legislation, policies, protocols, and good practice guidelines as a practitioner in order to ensure I meet my own roles and responsibilities when obtaining an individual’s history.

Other answers in the full document:

  • 1.2 Explain the guidelines to be followed if the individual is unable to provide a relevant history.
  • 1.3 Explain how to check a third party’s authority and ability to provide information about an individual.
  • 1.4 Outline the steps to be taken to clarify and confirm any missing or ambiguous information in an individual’s history.
  • 1.5 Explain own role and responsibilities in line with obtaining a client history.

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