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Elements and Performance Criteria

  1. Obtain client information
  2. Undertake basic physical examination
  3. Summarise and present findings

Required Skills

This describes the essential skills and knowledge and their level required for this unit

Essential knowledge

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

Organisation policies and procedures relating to

client confidentiality

referral including various levels of urgency

limits of own ability and authority

Basic anatomy and physiology of

circulatory system including blood pressure the pulse

skeletal system

endocrine system

respiratory tract

male and female urinary and genital tracts

gastrointestinal tract

the ear

the skin

the eye

components of mouth and tooth structure

Correct procedures and protocols used in the assessment of common client presentations

Normal range of test outcomes including

blood pressure for adults and children


pulse rate

respiratory and peak flow rates

Common conditions and associated presenting problems including

respiratory conditions

genitourinary conditions

gastrointestinal problems

ear conditions

eye problems

sexually transmitted infections

Basic knowledge relating to pregnancy and birthing including

basic mechanics of pregnancy and birthing

impact of smoking and alcohol in pregnancy

recognition of common or potentially serious pregnancy problems eg premature labour bleeding high BP


Essential knowledge continued

Basic knowledge of reproductive health including

physiology of conception

recognition of sexually transmitted infections STIs

contraceptive options

Links between environment and health including


clean water


food contamination

insect vectors

Basic nature of common diseases including

cardiovascular diseases

rheumatic fever and rheumatic heart disease


Key elements of accurate reporting via radio telephone in writing and during case discussion

Important elements of selfmanagement and supporting client selfmanagement of chronic conditions including an understanding of

attributes of selfmanagement

behavioural change

Essential skills

It is critical that the candidate demonstrate the ability to

Develop and apply knowledge of anatomy and physiology in undertaking clients observations questioning and measurements to assess health status

Use medical equipment safely and correctly

Identify significant variations from normal

Summarise and communicate health assessment findings

In addition the candidate must be able 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 the ability to

Conduct interpret document and report findings of simple routine assessments including

use a structured approach to assessment

take and record relevant details of clients history including body language

observe and assess clients health in line with guidance

use correct procedures and protocols to examine common client presentations

use medical equipment correctly

take standard precautions for infection control

summarise and report findings in line with organisation procedures and protocols

Accurately differentiate between urgent and nonurgent situations

Confidently recognise common uncomplicated health conditions from clinical features

Identify situations when assistance is required

Communicate effectively and establish a relationship of trust with clients and significant others

Elicit relevant information from client or documents

Clearly explain examination procedures and protocols to client

Contribute effectively to the preparation of client centred care plans including selfmanagement care plans for clients with chronic conditions

Make appropriate referrals providing accurate and relevant details to clients and referral agencies

Reflect on and improve own level and application of skills and knowledge to achieve desirable outcomes and maintain own capabilities

Evidence Required

The evidence guide provides advice on assessment and must be read in conjunction with the Performance Criteria Required Skills and Knowledge the Range Statement and the Assessment Guidelines for this Training Package

Critical aspects of assessment

The individual being assessed must provide evidence of specified essential knowledge as well as skills

Consistency of performance should be demonstrated over the required range of situations relevant to the workplace

Where for reasons of safety space or access to equipment and resources assessment takes place away from the workplace the assessment environment should represent workplace conditions as closely as possible

Conditions of assessment

This unit includes skills and knowledge specific to Aboriginal andor Torres Strait Islander culture

Assessment must therefore be undertaken by a workplace assessor who has expertise in the unit of competency or who has the current qualification being assessed and who is

Aboriginal or Torres Strait Islander himherself


accompanied and advised by an Aboriginal or Torres Strait Islander person who is a recognised member of the community with experience in primary health care

Context of assessment

Competence should be demonstrated working individually under supervision or as part of a primary health care team working with Aboriginal andor Torres Strait Islander clients

Assessment should replicate workplace conditions as far as possible

Related units

This unit may be assessed independently or in conjunction with other units with associated workplace application

Range Statement

The Range Statement relates to the unit of competency as a whole. It allows for different work environments and situations that may affect performance. Add any essential operating conditions that may be present with training and assessment depending on the work situation, needs of the candidate, accessibility of the item, and local industry and regional contexts.

Cultural respect

This competency standard supports the recognition, protection and continued advancement of the inherent rights, cultures and traditions of Aboriginal and Torres Strait Islander peoples

It recognises that the improvement of the health status of Aboriginal and Torres Strait Islander people must include attention to physical, spiritual, cultural, emotional and social well-being, community capacity and governance

Its application must be culturally sensitive and supportive of traditional healing and health, knowledge and practices

Community control

Community participation and control in decision-making is essential to all aspects of health work, and the role of the health worker is to support the community in this process


Supervision must be conducted in accordance with prevailing state/territory and organisation legislative and regulatory requirements

References to supervision may include either direct or indirect supervision of work by more experienced workers, supervisors, managers or other health professionals

A person at this level should only be required to make decisions about clients within the organisation's standard treatment protocols and associated guidelines

Legislative requirements

Federal, state or territory legislation may impact on workers' practices and responsibilities. Implementation of the competency standards should reflect the legislative framework in which a health worker operates. It is recognised that this may sometimes reduce the application of the Range of Variables in practice. However, assessment in the workplace or through simulation should address all essential skills and knowledge across the Range of Variables

Aboriginal and/or Torres Strait Islander health workers may be required to operate in situations that do not constitute 'usual practice' due to lack of resources, remote locations and community needs. As a result, they may need to possess more competencies than described by 'usual practice circumstances'

Under all circumstances, the employer must enable the worker to function within the prevailing legislative framework

An accurate history may include:

History of the presenting problem (character, severity and duration of symptoms)

Client concerns and beliefs regarding their problems

Past medical history, including use of alcohol, tobacco and other substances

Medicines being taken


Family and community circumstances, including identifying environmental health factors that may contribute to client's health problems

Basic dietary information, including diet history to determine food and drink intake

Related health care providers may include:

Personnel internal to the service provider

External health care providers

Other service providers

Client information may include:

Significant ongoing health problems

Current medications

Clinical progress notes relevant to the presenting problem

Record of allergies

Current support mechanisms

Standing orders/written care protocols include:

Written guidelines or orders that support the clinical assessment and management of presenting health problems (e.g. CARPA)

Medical equipment (to beused) includes:



Peak expiratory flow rate meters

Eye scope (ophthalmoscope)


Blood glucose testing units

Blood pressure testing unit (sphygmomanometer)

Eye chart (Snellen or Bailey-Lovie chart)

Tape measure (or stadiometer) for measuring height

Length mat (for babies)

Ear scope (otoscope)

Metered dose inhalers and spacers and nebulisers

Additional medical equipment that must berecognisedincludes:

Haemoglobin testing equipment

ECG machine

Spirometer (lung function tester)

Tympanometer (middle ear function)

Audiometer (hearing tester)

Resuscitation equipment

Retinal camera

Audiology equipment

Vital signs include:



Blood pressure

Respiratory rate

Blood sugar level

Non-clinical factors responsible for abnormal readings may include:

Failure to properly shake down a mercury thermometer

Effect of ingestion of hot or cold beverage on oral temperature measurement

Differences in temperature measurements taken at sites (i.e. oral, axillary, ear)

Effect of exertion and anxiety on pulse rate and blood pressure

Impact of cuff size on the accurate measurement of blood pressure

Faulty equipment

Failure to correctly calibrate equipment

Impact of environmental factors on equipment

Effect of food and drink on blood sugar reading

Common health conditions to be recognised include:

Upper respiratory tract infection

Acute and chronic suppurative otitis media

Hay fever

Tension headache


Uncomplicated gastroenteritis

Impetigo (school sores) and boils


Fungal skin infection

Mild asthma

Nappy rash

Poor dental health (gingivitis, cavities, tooth loss, pain)

Overweight and obese adults and children

Poor growth in infants and children

Clinical features suggesting potentially serious health problems include:

The 'unwell child'

Features suggesting dehydration

Chest pain, productive cough, haemoptysis, breathlessness or fast breathing

Pelvic pain, pain passing urine or blood in the urine

Abdominal tenderness or unexplained abdominal pain

Fever among high risk persons (infants, elderly and clients with chronic disease, valvular heart disease or past rheumatic fever)

Fever with features that might indicate serious infection (eg: abdominal pain, urinary symptoms, headache, productive cough, skin infection)

Wounds or sores that are deep, extensive, on the face or on the extremities of clients with diabetes

Unexplained weight loss

Heavy vaginal bleeding

Bleeding or pain in pregnancy

Potentially serious or complicated health conditions to be referred may include:

Serious infections (pneumonia, blood poisoning, meningitis, endocarditis, kidney infection)

Cancers (lung, bowel, throat, breast, leukaemia, prostate)

Heart disease (heart attack, angina&heart failure)

Asthma and chronic obstructive lung disease

Sexually transmitted infections (gonorrhoea, chlamydia, syphilis, HIV/AIDS, warts, genital herpes, pubic lice)

Pregnancy complications (miscarriage, ectopic pregnancy, placental abruption)

Surgical causes of abdominal pain (appendicitis, pancreatitis, biliary colic, renal stones, gall stones)

Stroke, spinal cord injury, intra-cerebral bleeding

Clinical assessment must include all assessments relevant to job role.

These may include:

Assessment for signs and symptoms of serious underlying causes of fever, including:

general appearance (the 'unwell child')

history of pain, respiratory symptoms, urinary symptoms or abdominal symptoms

history of diabetes, rheumatic fever or valvular heart disease

respiratory rate and pulse rate


examination of skin for infection

examination of ears and throat

Urine specimen collection using multi-reagent sticks and including:

mid-stream urine collection

first pass urine collection

paediatric bag collection

Simple abdominal examination, including:

locating site of tenderness

simple tests for peritoneal inflammation

presence of abdominal masses

Simple peripheral nerve examinations, including:

testing extremities (hands, feet) for light touch and sharp sensation

visible wasting of hand muscles

grip strength and finger abduction

Assessment of adult height/weight (body mass index) and waist circumference using correct equipment

Ear examinations, use of otoscope to identify abnormal appearance of tympanic membrane and/or ear canal

Basic oral health assessment, including:

visual inspection of oral cavity, teeth and gums

palpation of gums and jaw-line for tenderness

identification of common dental variations from normal

continued ...

Clinical assessment may include:

Clinical assessment of eye problems, including:

lid eversion

use of fluorescein staining

identification of the signs and symptoms of trachoma, using the WHO simplified trachoma grading system

screening for diabetic retinopathy

Visual acuity testing, including:

Snellen or Bailey-Lovie chart


counting fingers

light perception

Examination of children for signs of trachoma

Respiratory assessments, including:

measurement of adult, child and infant respiratory rates

measurement of peak expiratory flow rate (adult, child)

recognition of signs of respiratory distress



Blood sugar level (BSL) tests (for clients with diabetes) and blood glucose level (BGL) tests (to diagnose clients with diabetes)

Examination of extremities, including:

feet of people with diabetes are examined for protective sensation, ulcers, calluses, infections, nail condition and peripheral circulation

extremities of clients with Hansen's disease are examined for ulceration and infection

Peripheral circulation problems.

Assessment of infant and child growth, including:

Measure, document and plot weight and height and Body Mass Index (BMI) (for children over 2 years)

Measure, document and plot head circumference

Measure haemoglobin

Compare growth with major developmental milestones and identify potential delayed growth

Identify overweight and obesity

Identify possible causes of delayed growth

Identify symptoms of pregnancy and calculate expected date of delivery.


abnormal post-natal conditions

common or serious neonatal conditions.

Information to promote and maintain good health may include:

Summary of test results and readings

Information on links between heart disease and smoking, diet and physical activity

Information on management of uncomplicated gastrointestinal conditions, such as:

constipation (i.e. eat more fibre, drink more water, appropriate use of laxatives)

gastroenteritis (i.e. maintain fluid intake, eat according to appetite, continue breast-feeding, handwashing and infection control)

indigestion and heartburn (e.g. trial of antacids, avoid late meals, identify other aggravating factors - alcohol, aspirin, anti-inflammatory medicines, smoking)

food handling and storage.

Information on causes of health problems, such as:

ear problems (i.e. infection and relationship to poverty and crowding; traumatic and noise-induced deafness)

skin infections (i.e. crowding; poor access to water; high levels of scabies infestation)

Information on strategies to manage health problems, such as diabetes, including:

physical activity, healthy diet (low fat, low sugar, high fibre carbohydrates, high vegetables and fruits), weight loss and foot care (e.g. appropriate footwear, regular foot self-care, ongoing review)

use of medicines

importance of regular health checks.

Information on dental health, including:

link between dental health and diet
(i.e. consumption of simple sugars and developing dental caries; specific risks such as lolly-pops and baby bottle with sweet drinks or cow's milk; suckling on breast all night)

chart showing oral assessment findings and teeth development

good dental hygiene practices (regular brushing and use of dental floss)

importance of regular dental checks, especially for clients with rheumatic heart disease

Signs of respiratory distress include:

Raised respiratory rate

Raised pulse rate

Increased respiratory effort (use of accessory muscles, inspiratory in-drawing of soft tissues)

Inability to speak through breathlessness


Presentations of common sexually transmitted infections include:

Male urethral discharge and/or dysuria

Vaginal discharge

Female pelvic pain

Ulcerative genital disease

Genital lumps

Reasons for testing urine include:

Screening for urine infection

Screening for kidney disease

Assessment of possible renal trauma

Ante-natal care

Issues requiring mandatory notification may include:

Protection of children and others identified to be at risk

Issues defined by jurisdictional legislation and/or regulatory requirements

Issues specifically identified by the community or organisation policies