Lesson 2 - Preparing for a Structured Information-Gathering Appointment
1. Lesson Overview
Good preparation allows an information-gathering appointment to be safe, organised and useful to the clinical team.
The assistant practitioner should understand why the appointment has been arranged, which information they are expected to collect and how concerns will be escalated. They should also make sure that they have the correct form and that a supervising clinician is available when required.
Preparation should take place before the patient or family joins the appointment. The practitioner should not rely on reading the form for the first time while speaking with them.
Suggested duration: 60 minutes
Delivery method: Self-directed learning followed by discussion with a supervisor
Practical requirement: Preparation exercise using an approved WMI Psychiatry form
2. Learning Outcomes
By the end of this lesson learners should be able to:
Explain why preparation is important for safe information gathering.
Identify the information that should be reviewed before an appointment.
Confirm that they have the correct patient, form and appointment type.
Prepare a suitable environment for an in-person or remote appointment.
Explain their role and the purpose of the appointment clearly.
Confirm who is attending and who is providing the information.
Recognise consent, confidentiality or parental responsibility questions that require escalation.
Describe what arrangements should be in place for clinical support and emergencies.
3. The Lecture
Why preparation matters
A structured appointment may appear straightforward because the practitioner is following an established form. However poor preparation can lead to:
The wrong form being completed.
Important questions being missed.
Information being recorded in the wrong patient record.
The appointment exceeding the allocated time.
Confusion about the purpose of the appointment.
Clinical questions being answered outside the practitioner’s role.
Risk or safeguarding concerns not being escalated promptly.
Confidential information being discussed with an inappropriate person.
The patient or family losing confidence in the service.
Preparation helps the practitioner remain calm and focused. It also allows the patient or family to understand what will happen.
Understanding the appointment
Before the appointment the practitioner should establish:
The patient’s name.
The patient’s date of birth.
The patient’s Zanda identification number.
The appointment date and time.
Whether the appointment is in person or remote.
The purpose of the appointment.
Which assessment pathway it relates to.
Which form or template must be completed.
Who is expected to attend.
Who is expected to provide the information.
The expected duration.
Which clinician is supervising the work.
How to contact the supervising clinician.
What to do if the clinician is not immediately available.
The practitioner should not assume that all appointments within an assessment pathway have the same purpose.
For example an ADHD assessment may include separate appointments for background information, symptom information, clinical observation and feedback. An assistant practitioner should only complete the specific task that has been delegated to them.
Confirming the correct form
The practitioner must make sure that they have the approved form for that appointment.
Before starting they should check:
The title of the form.
Whether it is intended for a child or an adult.
Whether it should be completed by the patient, parent or another informant.
Whether it is the current approved version.
Whether all sections are available.
Where the completed information should be saved.
Whether any sections must only be completed by a clinician.
Whether the form contains questions that require immediate escalation if answered positively.
A form intended for parents should not automatically be used to interview the patient. An adult form should not be used for a child simply because the questions look similar.
If the practitioner is unsure whether the correct form has been provided they should check with their supervisor before the appointment begins.
Reviewing the patient record
The assistant practitioner should only review information needed to carry out the delegated task.
Relevant information may include:
The patient’s basic identifying details.
The reason for the appointment.
The assessment pathway.
The names of parents or carers expected to attend.
Communication needs.
Interpreter requirements.
Reasonable adjustments.
Known risks that may affect the safe conduct of the appointment.
Instructions left by the clinical team.
The name of the supervising clinician.
The purpose of this review is to prepare safely. It is not to form an opinion about the patient or search through unrelated clinical information.
The practitioner should avoid developing assumptions from previous records. The patient or family should be given an opportunity to provide their own account.
Avoiding confirmation bias
Previous notes may describe particular difficulties. The practitioner must not allow this information to shape the questions in a leading way.
For example the record may state that a parent previously reported hyperactivity.
The practitioner should ask:
“How would you describe their activity levels?”
They should not ask:
“The notes say they are very hyperactive. Is that still the case?”
The second question suggests what the expected answer should be.
Previous information can help the practitioner understand the purpose of the appointment. It should not be used to pressure the person into giving a consistent answer.
If the current account differs from previous information the practitioner should record the current account accurately. The clinician can review any differences.
Checking for communication needs
Patients and families may require adjustments to participate fully.
Examples include:
An interpreter.
Additional processing time.
Questions presented one at a time.
Short breaks.
Simple language.
Written as well as verbal information.
Reduced background noise.
Camera adjustments for remote appointments.
Support from a parent or carer.
Assistance because of hearing or visual difficulties.
A shorter appointment divided into more than one session.
The assistant practitioner should check the record for known adjustments. They should also ask at the beginning whether anything would make the appointment easier.
A helpful question is:
“Before we begin is there anything that would help you take part in the appointment or understand the questions?”
The practitioner should not make assumptions based on a diagnosis or disability.
If an adjustment cannot be provided the practitioner should contact the appropriate member of the team before proceeding.
Interpreter arrangements
A family member should not automatically be used as an interpreter for clinical information. This may affect accuracy, confidentiality and the person’s ability to speak freely.
If an interpreter is required the practitioner should confirm:
That an appropriate interpreter has been arranged.
The interpreter’s name or identification details.
The language and dialect required.
Whether the interpreter will attend remotely or in person.
How the interpreter will join the appointment.
Whether additional time has been allocated.
The practitioner should speak directly to the patient or family member rather than speaking about them to the interpreter.
Questions should be brief and clear. The practitioner should pause regularly to allow interpretation.
Any concern about the interpreter arrangement should be discussed with a supervisor.
Preparing the environment for an in-person appointment
The room should provide privacy and be suitable for a confidential conversation.
Before the appointment the practitioner should check:
That the correct room has been booked.
That the room is private.
That conversations cannot easily be overheard.
That the room is reasonably tidy and free from unnecessary distractions.
That seating is appropriate.
That any required forms or equipment are available.
That the computer system can be accessed securely.
That the practitioner knows how to request assistance.
That the practitioner knows the relevant emergency arrangements for the location.
Patient information should not be visible to other people. Previous documents should be removed from desks and computer screens should be locked whenever they are unattended.
Preparing for a remote appointment
For a video or telephone appointment the practitioner should use an approved system and work from a private environment.
Before the appointment they should check:
That the device is working.
That the internet connection is adequate.
That the camera and microphone work.
That headphones are available if required for privacy.
That the background is appropriate.
That other people cannot overhear the conversation.
That the correct secure meeting link has been sent.
That the patient’s telephone number is available in case the connection fails.
That the supervising clinician can be contacted.
That the practitioner knows what to do if the patient disconnects during a concerning disclosure.
The practitioner should not conduct an appointment from a public place or where household members can overhear confidential information.
Personal devices should only be used if this has been authorised and appropriate security arrangements are in place.
Preparing the documentation
The practitioner should know where they will record the information.
Depending on the approved workflow this may be:
Directly within the patient’s Zanda record.
Within an approved electronic form.
Within a clinical document stored in an approved location.
On an authorised paper form for later secure transfer.
The practitioner should not create personal notes on an unauthorised device or save patient information in a personal account.
Before the appointment they should:
Open the correct patient record.
Confirm the patient identifiers.
Open the correct form.
Check that changes can be saved.
Close unrelated patient records.
Make sure no information about another patient is visible.
If the system is not working the practitioner should follow the approved business continuity procedure. They should not create an improvised method of storing confidential information.
Confirming clinical support
An assistant practitioner must know how to access help.
Before the appointment they should identify:
The supervising clinician.
The clinician’s contact method.
Whether the clinician is immediately available.
The alternative contact if the clinician cannot be reached.
The process for urgent risk or safeguarding concerns.
The emergency procedure for the appointment location.
The incident reporting process.
If the appointment has the potential to involve risk information there must be a clear escalation arrangement.
The practitioner should not begin an appointment if safe supervision arrangements are absent and the task cannot be completed safely without them.
Starting the appointment
The opening of the appointment should establish safety, clarity and trust.
The practitioner should:
Introduce themselves.
State their role.
Confirm the identity of the patient.
Confirm who else is present.
Explain the purpose of the appointment.
Explain how the information will be used.
Clarify that clinical conclusions will be made by the qualified clinician.
Explain the expected duration.
Check whether any adjustments are needed.
Confirm that the patient or family is willing to proceed.
A suitable introduction might be:
“Hello. My name is [name] and I am an assistant practitioner with WMI Psychiatry. My role today is to help you work through the background information form and record the information you provide. I will not be making a diagnosis or giving treatment advice. The clinical team will review this information alongside the other parts of the assessment.”
The practitioner can then add:
“The appointment should take approximately [time]. We can pause if you need a short break. Before we begin I need to confirm some details and check who is present.”
Confirming identity
The practitioner must make sure that they are speaking with the correct patient or family.
They should follow the WMI Psychiatry identity-checking procedure. This will usually involve checking approved identifiers such as:
Full name.
Date of birth.
Address or postcode.
Zanda identification number where appropriate.
The practitioner should not disclose sensitive information before identity has been confirmed.
If the details do not match the record they should pause and seek advice. They should not change demographic information without following the approved process.
Confirming who is present
The practitioner should identify everyone attending the appointment.
This includes people who may be off camera or listening nearby during a remote appointment.
The record should include:
The patient’s name.
The name of each person attending.
Their relationship to the patient.
Whether an interpreter is present.
Whether anyone joins or leaves during the appointment.
Who provides each main part of the information.
A useful question during a remote appointment is:
“Before we start could you let me know who is in the room or able to hear the conversation?”
This is important for confidentiality and accurate documentation.
Appointments involving children and young people
A patient under 18 should be accompanied in line with WMI Psychiatry policy.
The practitioner should confirm:
Which adult is attending.
Their relationship to the child.
Whether they are expected to provide the information.
Whether the child will be involved in answering questions.
Whether any part of the appointment has been planned separately with the young person.
Whether the clinical team has provided specific instructions.
The assistant practitioner should not independently determine a dispute about parental responsibility, consent or access to information.
If there is uncertainty about whether an adult can participate or receive information the practitioner should pause and contact the clinical team.
Consent to continue
The practitioner should explain the appointment in a way the patient and family can understand. They should then check that they are willing to proceed.
Consent is an ongoing process. A person may agree at the beginning and later ask to pause or stop.
The practitioner should not pressure someone to answer a question. If the person does not wish to answer they should record this accurately.
For example:
“She stated that she did not wish to answer this question.”
The practitioner should not record the answer as negative or absent.
If the practitioner is concerned that the person does not understand the purpose of the appointment they should seek clinical advice.
Explaining confidentiality
The practitioner should explain that information will be recorded in the clinical record and shared with the professionals involved in the assessment or care.
They should not promise absolute confidentiality.
A suitable explanation is:
“The information you provide will be recorded in your clinical record and reviewed by the clinical team. We treat your information as confidential. If you tell me something that raises a serious concern about your safety or somebody else’s safety I may need to share it promptly with an appropriate clinician.”
Questions about withholding information from parents, carers or other professionals should be referred to the clinical team.
Checking whether the appointment remains appropriate
Circumstances may have changed since the appointment was booked.
The practitioner should seek advice if:
The expected informant is not present.
A different person attends without prior agreement.
The patient is in a public place.
Confidentiality cannot be maintained.
The patient appears too unwell or distressed to participate.
The patient is driving during a remote appointment.
There is a significant language barrier without an interpreter.
The wrong form has been allocated.
The appointment appears to require clinical assessment.
Safe supervision arrangements are unavailable.
The patient or family does not understand or agree to the purpose of the appointment.
It may be safer to rearrange an appointment than to continue under unsuitable circumstances. The decision should be discussed with the appropriate clinician or manager.
Time management
The practitioner should know how much time is available and how many sections must be completed.
At the beginning they can explain:
“We have approximately [time] today. I will guide us through each section so that we can cover the information requested by the clinical team.”
If a person gives very detailed answers the practitioner can respond respectfully:
“Thank you. I am going to bring us back to the question so that we have enough time to complete the remaining sections.”
The practitioner should not rush important information or interrupt a risk disclosure to keep to time.
If the form cannot be completed safely within the appointment the practitioner should record where they stopped and discuss the next steps with the clinical team.
Final preparation check
Immediately before starting the practitioner should be able to answer the following questions:
Am I in the correct patient record?
Do I have the correct form?
Do I understand the purpose of this appointment?
Do I know who is expected to attend?
Do I know what information I am authorised to collect?
Do I know which areas are outside my role?
Do I know how to contact my supervisor?
Do I know what to do if risk or safeguarding information is disclosed?
Is the environment private and suitable?
Is the documentation system working?
Am I personally ready to conduct the appointment?
If the answer to an essential safety question is no the practitioner should address this before beginning.
4. Clinical Perspective
Clinical pearl: Preparation should reduce uncertainty
The practitioner does not need to predict everything that might happen. They do need to know who to contact when something unexpected occurs.
A clear escalation route is more useful than attempting to memorise how to manage every possible clinical situation.
Clinical pearl: Begin with a clear explanation of the role
Families are less likely to seek clinical advice from the assistant practitioner if the role is explained clearly at the beginning.
A good introduction is warm and helpful while also setting an appropriate boundary.
Clinical pearl: Check the document before checking the clock
A practitioner who begins promptly with the wrong form has not saved time. Confirming the form and patient record should always come before starting the questions.
Clinical pearl: Know who supplied the information
The clinical team needs to understand whether information came from the patient, mother, father, teacher or another person.
Avoid writing “the family reports” if only one family member provided the answer.
Common pitfall: Reading too much of the record
Reviewing excessive background information can make the practitioner more likely to expect particular answers. Only access information required for the delegated task.
Common pitfall: Assuming the person is alone
During remote appointments another person may be present but out of view. Always check who can hear the conversation.
Common pitfall: Starting without an escalation route
Risk information can arise during any patient contact. The practitioner should not wait for a disclosure before working out how to contact the supervising clinician.
Common pitfall: Continuing because the appointment has been paid for or scheduled
Administrative pressure should not override safety, consent or confidentiality. If the circumstances are unsuitable the practitioner should seek advice.
5. Case Examples
Case Example 1: The wrong parent form
An assistant practitioner opens a developmental history form intended for a parent. The adult patient attends alone and states that they expected to complete an adult ADHD symptom interview.
The practitioner should not adapt the parent form during the appointment. They should explain that they need to confirm the correct appointment and contact the clinical team.
Case Example 2: Another person is in the room
During a video appointment the practitioner hears another person speaking in the background. The patient did not mention that anyone else was present.
The practitioner should pause and ask who is in the room or able to hear the conversation. They should check whether the patient is comfortable continuing.
If privacy cannot be established they should seek advice about rearranging the appointment.
Case Example 3: No supervising clinician is available
The practitioner is due to complete a form that includes questions about self-harm. They discover that the named clinician is unavailable and no alternative escalation contact has been identified.
The practitioner should contact the service manager or appropriate senior team member before starting. They should not proceed until there is a safe escalation arrangement.
Case Example 4: The parent is not present
A 14-year-old joins an appointment alone. The appointment was arranged to collect a developmental history from their mother.
The practitioner should not attempt to obtain a parental developmental history from the young person. They should follow the under-18 attendance procedure and contact the clinical team.
Case Example 5: The patient joins from a public place
An adult patient joins a video appointment from a café. Other people are sitting close enough to hear the conversation.
The practitioner should explain that the appointment involves confidential information and check whether the patient can move to a private location. If they cannot do so the practitioner should seek advice about rearranging the appointment.
6. Summary
Before an information-gathering appointment the assistant practitioner should:
Confirm the patient’s identity and appointment details.
Understand the purpose of the appointment.
Open the correct approved form.
Review only the information needed for the task.
Check for communication needs and reasonable adjustments.
Prepare a private and suitable environment.
Confirm that the documentation system is available.
Identify the supervising clinician and escalation process.
Know what to do if technology fails.
Be clear about the limits of their role.
At the beginning of the appointment they should:
Introduce themselves and explain their role.
Confirm the patient’s identity.
identify everyone present.
Explain how the information will be used.
Check confidentiality and privacy.
Confirm that the patient or family is willing to proceed.
Check whether any adjustments are required.
Explain the approximate structure and duration.
Good preparation supports accurate information gathering and reduces avoidable risk.
7. Further Reading
WMI Psychiatry Assistant Practitioner Role Description
WMI Psychiatry Consent and Confidentiality Policy
WMI Psychiatry Safeguarding Policy
WMI Psychiatry Risk Assessment and Escalation Procedure
WMI Psychiatry Information Governance Policy
WMI Psychiatry Remote Consultation Procedure
WMI Psychiatry Business Continuity Policy
The guidance for each approved information-gathering form
8. Reflective Exercise
The learner should consider the following questions:
What information would you need before conducting your first appointment?
How would you explain your role without making the patient feel that the appointment is unimportant?
What would you do if you noticed that the wrong patient record was open?
How would you respond if a patient joined a video appointment while travelling on public transport?
Who would you contact if the supervising clinician was unavailable?
Where would you find the relevant risk and safeguarding procedures?
What reasonable adjustments might help a patient with attention or processing difficulties?
The learner should discuss their answers with their supervisor.
9. Practical Competency Activity
The learner should be given an approved WMI Psychiatry information-gathering form and a fictional appointment scenario.
They should demonstrate that they can:
Identify the purpose of the appointment.
Confirm that the form is appropriate for the patient and informant.
Identify the information needed from the clinical record.
Prepare an appropriate room or remote working environment.
Locate the relevant escalation procedure.
Identify the supervising clinician and alternative contact.
Deliver a clear opening explanation.
Confirm identity and who is present.
Explain confidentiality appropriately.
Check consent and communication needs.
The supervisor should provide feedback and record whether further teaching or practice is required.
10. Knowledge Check
Complete the short knowledge check below to consolidate your learning and check your understanding of the key principles covered in this lesson. You can review the lesson content again before submitting your answers.
