Assessor Resource

HLTDEF003
Perform the duties of a scribe during casualty resuscitation

Assessment tool

Version 1.0
Issue Date: April 2024


This unit describes the skills and knowledge required to accurately obtain and document casualty information from various sources during a resuscitation.

This unit applies to Australian Defence Force (ADF) personnel working as part of a resuscitation team in an operational context.

The skills in this unit must be applied in accordance with Commonwealth and State/Territory legislation, Australian/New Zealand standards and industry codes of practice.

You may want to include more information here about the target group and the purpose of the assessments (eg formative, summative, recognition)



Evidence Required

List the assessment methods to be used and the context and resources required for assessment. Copy and paste the relevant sections from the evidence guide below and then re-write these in plain English.

ELEMENT

PERFORMANCE CRITERIA

Elements define the essential outcomes

Performance criteria describe the performance needed to demonstrate achievement of the element

1. Prepare for the role of scribe

1.1 Prepare resuscitation documentation prior to arrival of casualty

1.2 Prepare resuscitation area to receive the casualtyin accordance with preliminary clinical data obtained and direction from resuscitation team leader

1.3 Prepare own personal protective equipment in accordance with organisation policies and procedures

1.4 Follow guidance from team leader and resuscitation team members in accordance with prescribed role

2. Participate as a scribe in the resuscitation

2.1 Follow personal hygiene and infection control procedures

2.2 Ascertain casualty identity and history and record accurately

2.3 Record treatment information and casualty’s response to treatment

2.4 Maintain chronological record of events and procedures of the resuscitation

2.5 Communicate relevant treatment information to other team members to aid in the continuity of care of the casualty

3. Perform post resuscitation duties

3.1 Accurately complete all relevant documentation

3.2 Provide documentation to team leader for authorisation

3.3 Organise ongoing casualty transfer in accordance with procedures

3.4 Refurbish resuscitation area in preparation for the next resuscitation

3.5 Participate in post event team debrief as applicable

The candidate must show evidence of the ability to complete tasks outlined in elements and performance criteria of this unit, manage tasks and manage contingencies in the context of the job role. There must be evidence that the candidate has:

completed the following tasks at least 3 times in line with governing regulations, trauma codes of practice and workplace procedures:

interpreted clinical data from multiple resources and accurately recorded details chronologically within emergency time constraints

recorded the following clinical information in a legible and clear manner:

medication

observations

assessment outcomes

interventions

referrals

pathology specimens

consumables (i.e. traceable with serial numbers)

operated/interpreted the following basic resuscitation equipment:

vital signs monitoring

intra-venous lines and fluids

monitors

used effective communication and teamwork skills:

active listening

questioning

feedback

information sharing

completed basic arithmetic calculations and recorded numbers

The candidate must be able to demonstrate essential knowledge required to effectively complete tasks outlined in elements and performance criteria of this unit, manage tasks and manage contingencies in the context of the work role. This includes knowledge of:

legal, ethical and military requirements for scribe work:

codes of practice

duty of care

infection prevention and control

informed consent

mandatory reporting

privacy, confidentiality and disclosure

records management and documentation

rights and responsibilities of workers, employers and clients

specific information sources that inform work practice:

Primary clinical care manual (PCCM)

organisation/unit standard operating procedures

current operational mandate

work role boundaries – responsibilities and limitations

work health and safety

documentation used for casualty resuscitation purposes, including associated pathology requirements

personal protective equipment requirements

standard resuscitation equipment schedules and operation

clinical monitoring requirements for resuscitation

documentation processes relevant to receiving and resuscitating a casualty

medical terminology

basic anatomy and physiology of all body systems

general resuscitation protocols provided by Australian Resuscitation Council (ARC)

general pathology and investigative requirements pertaining to standard resuscitation processes

inter-departmental transfer requirements

role of other resuscitation team members and support services

storage and security requirement for personal effects (including weapons, explosives and pyrotechnics)

Skills must have been demonstrated in the workplace or in a simulated environment that reflects workplace conditions. The following conditions must be met for this unit:

use of suitable facilities, equipment and resources, including:

a resuscitation bay mimicking the work environment

casualties (high fidelity simulation, resuscitation mannequins and/or actors)

documentation used within the resuscitative environment

pathology samples/containers requiring labelling

modelling of industry operating conditions, including:

a minimum of 3 people in the resuscitation team

a minimum of 1-2 other personnel supporting the resuscitation

Assessors must satisfy the Standards for Registered Training Organisations (RTOs) 2015/AQTF mandatory competency requirements for assessors. In addition, assessors must have at least 3 years’ experience as a health professional in a resuscitative/emergency department setting.


Submission Requirements

List each assessment task's title, type (eg project, observation/demonstration, essay, assingnment, checklist) and due date here

Assessment task 1: [title]      Due date:

(add new lines for each of the assessment tasks)


Assessment Tasks

Copy and paste from the following data to produce each assessment task. Write these in plain English and spell out how, when and where the task is to be carried out, under what conditions, and what resources are needed. Include guidelines about how well the candidate has to perform a task for it to be judged satisfactory.

ELEMENT

PERFORMANCE CRITERIA

Elements define the essential outcomes

Performance criteria describe the performance needed to demonstrate achievement of the element

1. Prepare for the role of scribe

1.1 Prepare resuscitation documentation prior to arrival of casualty

1.2 Prepare resuscitation area to receive the casualtyin accordance with preliminary clinical data obtained and direction from resuscitation team leader

1.3 Prepare own personal protective equipment in accordance with organisation policies and procedures

1.4 Follow guidance from team leader and resuscitation team members in accordance with prescribed role

2. Participate as a scribe in the resuscitation

2.1 Follow personal hygiene and infection control procedures

2.2 Ascertain casualty identity and history and record accurately

2.3 Record treatment information and casualty’s response to treatment

2.4 Maintain chronological record of events and procedures of the resuscitation

2.5 Communicate relevant treatment information to other team members to aid in the continuity of care of the casualty

3. Perform post resuscitation duties

3.1 Accurately complete all relevant documentation

3.2 Provide documentation to team leader for authorisation

3.3 Organise ongoing casualty transfer in accordance with procedures

3.4 Refurbish resuscitation area in preparation for the next resuscitation

3.5 Participate in post event team debrief as applicable

The candidate must show evidence of the ability to complete tasks outlined in elements and performance criteria of this unit, manage tasks and manage contingencies in the context of the job role. There must be evidence that the candidate has:

completed the following tasks at least 3 times in line with governing regulations, trauma codes of practice and workplace procedures:

interpreted clinical data from multiple resources and accurately recorded details chronologically within emergency time constraints

recorded the following clinical information in a legible and clear manner:

medication

observations

assessment outcomes

interventions

referrals

pathology specimens

consumables (i.e. traceable with serial numbers)

operated/interpreted the following basic resuscitation equipment:

vital signs monitoring

intra-venous lines and fluids

monitors

used effective communication and teamwork skills:

active listening

questioning

feedback

information sharing

completed basic arithmetic calculations and recorded numbers

The candidate must be able to demonstrate essential knowledge required to effectively complete tasks outlined in elements and performance criteria of this unit, manage tasks and manage contingencies in the context of the work role. This includes knowledge of:

legal, ethical and military requirements for scribe work:

codes of practice

duty of care

infection prevention and control

informed consent

mandatory reporting

privacy, confidentiality and disclosure

records management and documentation

rights and responsibilities of workers, employers and clients

specific information sources that inform work practice:

Primary clinical care manual (PCCM)

organisation/unit standard operating procedures

current operational mandate

work role boundaries – responsibilities and limitations

work health and safety

documentation used for casualty resuscitation purposes, including associated pathology requirements

personal protective equipment requirements

standard resuscitation equipment schedules and operation

clinical monitoring requirements for resuscitation

documentation processes relevant to receiving and resuscitating a casualty

medical terminology

basic anatomy and physiology of all body systems

general resuscitation protocols provided by Australian Resuscitation Council (ARC)

general pathology and investigative requirements pertaining to standard resuscitation processes

inter-departmental transfer requirements

role of other resuscitation team members and support services

storage and security requirement for personal effects (including weapons, explosives and pyrotechnics)

Skills must have been demonstrated in the workplace or in a simulated environment that reflects workplace conditions. The following conditions must be met for this unit:

use of suitable facilities, equipment and resources, including:

a resuscitation bay mimicking the work environment

casualties (high fidelity simulation, resuscitation mannequins and/or actors)

documentation used within the resuscitative environment

pathology samples/containers requiring labelling

modelling of industry operating conditions, including:

a minimum of 3 people in the resuscitation team

a minimum of 1-2 other personnel supporting the resuscitation

Assessors must satisfy the Standards for Registered Training Organisations (RTOs) 2015/AQTF mandatory competency requirements for assessors. In addition, assessors must have at least 3 years’ experience as a health professional in a resuscitative/emergency department setting.

Copy and paste from the following performance criteria to create an observation checklist for each task. When you have finished writing your assessment tool every one of these must have been addressed, preferably several times in a variety of contexts. To ensure this occurs download the assessment matrix for the unit; enter each assessment task as a column header and place check marks against each performance criteria that task addresses.

Observation Checklist

Tasks to be observed according to workplace/college/TAFE policy and procedures, relevant legislation and Codes of Practice Yes No Comments/feedback
 
Prepare resuscitation documentation prior to arrival of casualty 
Prepare resuscitation area to receive the casualtyin accordance with preliminary clinical data obtained and direction from resuscitation team leader 
Prepare own personal protective equipment in accordance with organisation policies and procedures 
Follow guidance from team leader and resuscitation team members in accordance with prescribed role 
Follow personal hygiene and infection control procedures 
Ascertain casualty identity and history and record accurately 
Record treatment information and casualty’s response to treatment 
Maintain chronological record of events and procedures of the resuscitation 
Communicate relevant treatment information to other team members to aid in the continuity of care of the casualty 
Accurately complete all relevant documentation 
Provide documentation to team leader for authorisation 
Organise ongoing casualty transfer in accordance with procedures 
Refurbish resuscitation area in preparation for the next resuscitation 
Participate in post event team debrief as applicable 

Forms

Assessment Cover Sheet

HLTDEF003 - Perform the duties of a scribe during casualty resuscitation
Assessment task 1: [title]

Student name:

Student ID:

I declare that the assessment tasks submitted for this unit are my own work.

Student signature:

Result: Competent Not yet competent

Feedback to student

 

 

 

 

 

 

 

 

Assessor name:

Signature:

Date:


Assessment Record Sheet

HLTDEF003 - Perform the duties of a scribe during casualty resuscitation

Student name:

Student ID:

Assessment task 1: [title] Result: Competent Not yet competent

(add lines for each task)

Feedback to student:

 

 

 

 

 

 

 

 

Overall assessment result: Competent Not yet competent

Assessor name:

Signature:

Date:

Student signature:

Date: