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Elements and Performance Criteria

1. Elements define the essential outcomes.
2. Assess client’s health
   • Build and maintain relationship of trust with each client, with active promotion of and strict adherence to confidentiality
   • Undertake detailed assessment in line with protocols for specific health condition/s
   • Review client records to determine priorities and potential areas of risk for each client
   • Evaluate impact of previous care strategies
   • Initiate relevant examinations and tests as required to identify and/or clarify any suspected or identified health issues and/or abnormalities
   • Communicate with the client in a culturally appropriate and safe manner in relation to any health issues and/or abnormalities and to inform ongoing health management
3. Interpret common pathology tests
   • Explain significance of common haematological, biochemical and microbiological test abnormalities to clients in plain language
   • Assess numerical test values against normal reference ranges
   • Refer abnormal pathology test results to medical practitioners as appropriate
4. Develop care plan
   • Formulate care plan to address identified health issues
   • Develop care plan with reference to the relevant health care team and other health care providers
   • Develop care plan in collaboration with the client
   • Propose treatment in accordance with organisation policies and procedures and as negotiated with the client, their family and/or the community
   • Include measures consistent with standing orders/written protocols, based on health assessment findings
   • Refer client as required to relevant health professionals in line with community, organisation and regulatory requirements
   • Document health care plan in the client’s file in accordance with organisation policies and procedures
5. Implement care plan
   • Provide care (treatment) to address identified health issues and manage chronic health problems
   • Encourage client to undertake regular health reviews to address identified health issues
   • Encourage client to maintain identified care practices to address the health issues
   • Monitor client health regularly to assess impact of treatment/s and care services
   • Provide client with information relevant to promoting and maintaining their health in a way they understand
   • Support client with information about each aspect of the care plan and the rationale for its inclusion
   • Initiate action (including referral) as determined by effective decision-making, in line with organisation policies, based on results of clinical assessment and in accordance with accepted procedures and protocols
   • Conduct treatment in accordance with the care plan, organisation policies and procedures and occupational health and safety requirements
   • Use medical equipment correctly and maintain equipment in accordance with manufacturer’s specifications and organisation policies
   • Maintain current, complete, accurate and relevant records for each client contact
6. Review care plan
   • Use regular client health checks as a way of monitoring and reviewing health care plan
   • Evaluate ongoing client health against identified criteria and make changes or referral, as determined by client’s condition and organisation procedures
   • Communicate effectively with the client and significant others to evaluate effectiveness of health care
7. Assess client’s health
   • Build and maintain relationship of trust with each client, with active promotion of and strict adherence to confidentiality
   • Undertake detailed assessment in line with protocols for specific health condition/s
   • Review client records to determine priorities and potential areas of risk for each client
   • Evaluate impact of previous care strategies
   • Initiate relevant examinations and tests as required to identify and/or clarify any suspected or identified health issues and/or abnormalities
   • Communicate with the client in a culturally appropriate and safe manner in relation to any health issues and/or abnormalities and to inform ongoing health management
8. Interpret common pathology tests
   • Explain significance of common haematological, biochemical and microbiological test abnormalities to clients in plain language
   • Assess numerical test values against normal reference ranges
   • Refer abnormal pathology test results to medical practitioners as appropriate
9. Develop care plan
   • Formulate care plan to address identified health issues
   • Develop care plan with reference to the relevant health care team and other health care providers
   • Develop care plan in collaboration with the client
   • Propose treatment in accordance with organisation policies and procedures and as negotiated with the client, their family and/or the community
   • Include measures consistent with standing orders/written protocols, based on health assessment findings
   • Refer client as required to relevant health professionals in line with community, organisation and regulatory requirements
   • Document health care plan in the client’s file in accordance with organisation policies and procedures
10. Implement care plan
    • Provide care (treatment) to address identified health issues and manage chronic health problems
    • Encourage client to undertake regular health reviews to address identified health issues
    • Encourage client to maintain identified care practices to address the health issues
    • Monitor client health regularly to assess impact of treatment/s and care services
    • Provide client with information relevant to promoting and maintaining their health in a way they understand
    • Support client with information about each aspect of the care plan and the rationale for its inclusion
    • Initiate action (including referral) as determined by effective decision-making, in line with organisation policies, based on results of clinical assessment and in accordance with accepted procedures and protocols
    • Conduct treatment in accordance with the care plan, organisation policies and procedures and occupational health and safety requirements
    • Use medical equipment correctly and maintain equipment in accordance with manufacturer’s specifications and organisation policies
    • Maintain current, complete, accurate and relevant records for each client contact

Performance Evidence

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, on at least three different occasions:

undertaken a detailed health assessment of Aboriginal and/or Torres Strait Islander clients, including adults and children

reviewed all relevant information for clients, including past treatment plans, to support the health assessment

carried out, and interpreted the outcomes of, relevant tests and examinations to identify and clarify specific health issues

developed care plans for clients, including treatment, in consultation with relevant health care team and health care professionals

communicated all aspects of the health care plan to clients and/or family in a culturally appropriate and safe manner, encouraging understanding and questions

implemented the health care plan by:

initiating treatment, including administering specific treatment procedures

referring clients to appropriate health services

using medical equipment necessary to determined treatment actions

monitoring the client’s progress and adjusting treatment as required to support health

supporting the client to engage in their health care plan by providing information to the client about their specific health issues

using client appointments to review the progress of the client under the treatment plan

documented all stages of the assessment, planning and implementation of health care

communicated at all times with the client in culturally appropriate and safe ways to support their health treatment, during the assessment, and planning and implementation of treatment

exercised decision-making and problem-solving skills in their treatment of clients

consulted and referred to other health professionals as required to support client care.

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Knowledge Evidence

The candidate must be able to demonstrate essential knowledge required to effectively do the task outlined in elements and performance criteria of this unit, manage the task and manage contingencies in the context of the identified work role.

This includes knowledge of:

key aspects of anatomy/physiology, pharmacology, and microbiology, associated with a range of health conditions including chronic conditions health

common treatments and associated care services and treatments relevant to client’s overall health

availability, effectiveness and risks associated with identified treatments and associated care services

other conditions that may occur and require concurrent management

commonly requested pathology tests, their indications, normal ranges and implications for client care management, including:

full blood examination and ESR

random and fasting blood sugars

glycated haemoglobin

electrolytes and creatinine

liver function tests

lipid tests

thyroid function tests

iron studies

cardiac enzymes

urinary albumin-creatinine ratio

tests for sexually transmissible infections

microscopy, culture and sensitivities

administration of specific procedures, including:

nasogastric tube (NGT) insertion and the management of fluids and medications

intraosseous (bone marrow) insertion and cannulation

complex wound and burns management

assessment and examination of lungs and respiratory system

insertion of an indwelling catheter (IDC)

application of POP

intravenous therapy administration and management, and fluid balance assessment and management

intravenous cannula insertion in adult and paediatrics

organisational standards, policies and procedures.

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