Elements and Performance Criteria
- Prepare for clinical assessment
- Prepare client for clinical assessment
- Explain clinical assessment clearly and simply to the client
- Give client is given the opportunity to ask questions and discuss concerns
- Gain informed consent from client in accordance with clinical guidelines, organisation policies and procedures
- Assure and maintain confidentiality of client information
- Obtain and record a medical history and client profile
- Conduct a physical examination
- Follow personal hygiene and infection control procedures
- Measure and record vital signs in accordance with clinical guidelines, organisation policies and procedures
- Conduct examination using appropriate physical examination techniques according to clinical guidelines, organisation policies and procedures
- Record examination outcomes in accordance with clinical guidelines, organisation policies and procedures
- Make a clinical assessment
- Make clinical assessment according to applied clinical reasoning and organisation policies and procedures
- Determine need for referral for extended physical examination and/or further diagnostic procedures
- Use information gathered through the clinical assessment to the develop treatment plan
- Arrange appropriate referral as required
- Conclude clinical assessment
- Explain clinical assessment findings clearly and simply to the client
- Record clinical findings in a way that can be interpreted readily by others and according to clinic guidelines, organisation policies and procedures
- Clean and/or dispose of equipment and consumables in accordance with manufacturers' requirements and infection control policy
- Store equipment and consumables in accordance with organisation policy and procedures