F069 04 (EUSC2) Obtain supporting information to inform the assessment of an individual

About this Unit

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

Scope

The scope is here to give you guidance on possible areas to be covered in this Unit. The terms in this section give you a list of options linked with items in the performance criteria. You need to provide evidence for any option related to your work area.

Individual - Individual who:

  • is a child or young person
  • is an adult of working age
  • is an older person
  • has communication differences

Information - Information on:

  • the nature and severity of symptoms
  • the duration/persistence of symptoms
  • pre-existing medical conditions
  • the individual’s home/social circumstances and functional capabilities
  • personal details (including age, height/weight, occupation, hobbies relevant to the incident and/or presenting symptoms, religious beliefs affecting possible treatments etc)
  • medications and treatments being taken/followed (including homeopathic and complementary medicine)
  • allergies
  • prosthetics being used (including false teeth, contact lenses, limb replacements etc)
  • surgical implants (including pace makers, joint replacements etc)
  • the name and address of the individual’s GP
  • the events leading up to the individual requiring immediate medical assistance
  • any actions taken or events that have happened since the individual first required immediate medical assistance
  • next of kin/significant others

Presenting symptoms - Presenting symptoms in relation to:

  • breathlessness
  • bleeding and fluid loss
  • pain
  • tissue trauma
  • skin rashes/dermatological features
  • toxic ingestion
  • altered consciousness, dizziness, faints and fits
  • altered behaviour
  • fever
  • a fall
  • ear, nose and throat problems
  • unwell older person
  • unwell child or young person

Source - Source to include:

  • persons in authority at the location where the event leading to the individual requiring immediate medical assistance took place
  • providers of other health and social care services to the individual (e.g. their GP, care warden etc)
  • electronic and/or paper records kept within your own service (e.g. pharmacy computer records, diabetes database, records department files etc)
  • people acting in loco parentis for a child (e.g. school teacher, group leader)
  • witnesses to an event which has led to the individual requiring immediate medical assistance

Evidence Requirements for the Unit

It is essential that you adhere to the Evidence Requirements for this Unit – please see details overleaf.

Specific Evidence Requirements for this Unit
Simulation:
  • Simulation is NOT permitted for any part of this unit.

The following forms of evidence are mandatory:
  • Direct observation: Your assessor/expert witness must observe you in real work activities, which provides evidence for a significant number of the performance criteria for this unit. You should be observed obtaining supporting information for the assessment of an individual. The observation should include how you relate to individuals and communicate with them.
  • Reflective accounts/professional discussion: These will be descriptions of your practice in obtaining information. You should be able to give examples of how you how you overcame any communication difficulties, how consent was obtained and how you interact with the individuals obtaining the information from.

Competence of performance and knowledge could also be demonstrated using a variety of evidence from the following:
  • Questioning: may be used to provide evidence of knowledge, legislation, policies and procedures, which cannot be fully evidenced through direct observation or reflective accounts. In addition the assessor/expert witness may also ask questions to clarify aspects of your practice.
  • Witness testimony: can be a confirmation or authentication of the activities described in your evidence, which your assessor has not seen. This could be provided by a work colleague or significant other

Work Products: These can be any records that you would normally use within your work role e.g. written history sheets. Product evidence will be important for this unit. NB Confidential records are not required to be in your portfolio, they can remain where they are normally stored and checked by your assessors and verifier. If they are included they must be made anonymous

  • APL/Assignment/Project: You may have already completed a project or assignment from Vocationally Related Qualification; you may also have evidence form other training e.g. Recording and Reporting. Communication Skills.

General guidance
  • Prior to commencing this Unit you should agree and complete an assessment plan with your assessor which details the assessment methods you will be using, and the tasks you will be undertaking to demonstrate your competence.
  • Evidence must be provided for ALL of the performance criteria ALL of the knowledge and the parts of the scope that are relevant to your job role.
  • The evidence must reflect the policies and procedures of your workplace and be linked to current legislation, values and the principles of best practice within Health Settings. This will include the National Service Standards and/or KSF for your areas of work and the individuals you care for.
  • All evidence must relate to your own work practice.

Knowledge specification for this unit

Competent practice is a combination of the application of skills and knowledge informed by values and ethics. This specification details the knowledge and understanding required to carry out competent practice in the performance described in this Unit.

When using this specification it is important to read the knowledge requirements in relation to expectations and requirements of your job role.

You need to provide evidence for ALL knowledge points listed below. There are a variety of ways this can be achieved so it is essential that you read the ‘knowledge evidence’ section of the Assessment Guidance.

You need to show that you know, understand and can apply in practice: / Enter Evidence Numbers
Legislation, policy and good practice
  1. A factual awareness of the legislation (national and European) relating to the work being undertaken, the context in which it takes place and the individuals with whom one works; codes of good practice which support the implementation of legislation (such as the Data Protection Act); how to interpret and apply relevant legislation to the work being undertaken.

  1. An in-depth understanding of why it is important to establish informed consent to the sharing of information, where the individual or third party is able to provide this, and what steps can be taken when this is not provided

  1. A factual awareness of 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

  1. A working understanding of the steps you would take to ensure that the privacy, dignity, wishes and beliefs of the individual are maintained

  1. A working understanding of the organisational policy and practices with regard to the confidentiality of information

Care and Support of the Individual
  1. A working understanding of how communication style may be modified to ensure it is appropriate to the individual’s level of understanding, culture and background, preferred ways of communicating and needs

  1. A working understanding of what sort of obstacles to communication can arise and the actions to be taken to manage them in a constructive manner

  1. An in-depth understanding of 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

Procedures and techniques
  1. A factual awareness of the reasons why your role and responsibilities should always be explained when taking information

  1. A working understanding of the types of information that need to be gathered and why each is necessary

  1. An in-depth understanding of why information needs to be gathered over a sufficient period of time and how this might vary from context to context

  1. A working understanding of 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

  1. An in-depth understanding of what sort of information it would be important to capture about the circumstances leading up to an individual requiring immediate medical assistance

Records and documentation
  1. An in-depth understanding of the importance of recording information clearly, accurately and in a systematic manner

Performance criteria
DO / RA / EW / Q / P / WT
  1. explain clearly:
  • your role and responsibilities
  • what information you need
  • the reasons why you need the information
  • with whom the information will be shared

  1. respect the individual’s privacy, dignity, wishes and beliefs in your interactions with other people

  1. check and confirm that the information is reliable, current and relates to the individual

  1. check and confirm whether anyone 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

  1. obtain informed consent from anyone acting as the source of information, where appropriate, to share the information they provide about the individual requiring immediate medical assistance

  1. 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

  1. use appropriate questions to explore, clarify and confirm any unusual or ambiguous information

  1. maintain clear and accurate records clearly and accurately in a systematic and logical manner that clearly shows the history of the individual’s condition and the source of the information obtained

  1. support the assessment with as complete and accurate a picture of the individual as possible

DO = Direct ObservationRA = Reflective AccountQ = Questions

EW = Expert Witness P = Product (Work)WT = Witness Testimony

Performance criteria
DO / RA / EW / Q / P / WT
  1. treat all information provided to you as confidential in accordance with organisational policy and practice

  1. communicate with people in a manner which:
  • is consistent with their level of understanding, culture, background and preferred ways of communicating
  • acknowledges the purpose of the communication
  • is appropriate to the context
  • encourages their participation
  • responds to communications of any kind from them

  1. constructively manage any obstacles to communication

DO = Direct ObservationRA = Reflective AccountQ = Questions

EW = Expert Witness P = Product (Work)WT = Witness Testimony

To be completed by the Candidate
I SUBMIT THIS AS A COMPLETE UNIT
Candidate’s name: ……………………………………………
Candidate’s signature: ………………………………………..
Date: …………………………………………………………..
To be completed by the Assessor
It is a shared responsibility of both the candidate and assessor to claim evidence, however, it is the responsibility of the assessor to ensure the accuracy/validity of each evidence claim and make the final decision.
I certify that sufficient evidence has been produced to meet all the elements, pcS AND KNOWLEDGE OF THIS UNIT.
Assessor’s name: …………………………………………….
Assessor’s signature: ………………………………………....
Date: …………………………………………………………..
Assessor/Internal Verifier Feedback
To be completed by the Internal Verifier if applicable
This section only needs to be completed if the Unit is sampled by the Internal Verifier
Internal Verifier’s name: ……………………………………………
Internal Verifier’s signature: ………………………………………..
Date: ……………………………………..…………………………..

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Unit: F069 04 (EUSC2) Obtain supporting information to inform the assessment of an individual