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2 – 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 roles and responsibilities when obtaining an individual’s history in health and social care involve the following:

  • Ensure that my communication with the individual respects their dignity at all times while gathering relevant details of his/her past health background, including medications taken if applicable, physical conditions, etc., through effective questioning techniques without causing undue distress to them during such conversations­–at no point should they feel obligated to disclose sensitive matters against their will if they do not wish.
  • Document accurate notes of everything discussed during consultation as part of a comprehensive record-keeping process and store it securely according to confidential procedures outlined by appropriate local government agencies and hospital systems, sharing it only on a “need-to-know” basis with authorised personnel who have been granted permission to access them by patients/guardians.
  • When obtaining a client’s history, adhere to best practices and guidelines established by the relevant health and social care governing body, such as the NHS, HSPC, and others, to ensure the accuracy of information obtained in an ethical manner.
  • Promote and ensure confidentiality of the individual’s medical history throughout the entire process.
  • Ensure that all information about a person is kept up to date in accordance with regulations.
  • Ask for consent from individuals before recording any personal information or sharing their health history with other professionals or family members.
  • Ensure that any information collected is relevant to the individual’s health condition or needs. Unnecessary questions should not be asked.
  • Ensure that I follow all applicable legislation, national guidelines, policies, protocols and good practice guidelines related to data protection and patient confidentiality/privacy rights.
  • Adhere to the Data Protection Act 2018, which outlines provisions for handling and processing of personal information, including principles such as purpose limitation and data minimisation when obtaining an individual’s history.
  • Follow the National Institute for Health & Care Excellence (NICE) guidelines on how to assess, manage and provide care when obtaining a patient’s history in health and social care settings.
  • Ensure that I work within professional boundaries while gathering information from individuals according to applicable codes of practice, such as the Code of Practice issued by the Health and Care Professions Council (HCPC).

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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