Elements and Performance Criteria
- Determine the scope of the assessment and the client's needs
- Establish client's purpose for consultation and identify symptoms experienced
- Determine client's eligibility for service using clinic/personal policies
- Explain services able to be provided and limits of available services clearly.
- Explore and clarify client's expectation of the service/clinic
- Identify factors likely to have a negative impact on assessment in consultation with the client and implement strategies to minimise the effects of these factors wherever possible
- Define personal abilities, level of professional competence and parameters of role to the client and ensure they determine practice at all times
- Refer clients are referred to other health care providers where their needs are identified as beyond the scope of the services able to be provided, or if in the opinion of the practitioner the needs of the clients are best met by doing so
- Identify and promote legal rights of the client are identified and promoted
- Obtain and record an accurate history of the client
- Seek information required from the client for the client's history is sought in an respectful way with all enquiries asked in a purposeful, systematic and diplomatic manner
- Collect and record accurate, relevant and well organised information in a form which can be interpreted readily by other professionals
- Treat information as confidential and store securely
- Manage the health assessment
- Obtain informed client consent prior to conducting tests in accordance with legislative requirements
- Pursue and investigate abnormal findings in a deliberate, logical and appropriate manner
- Assess reliability of data obtained and establish appropriate clinical correlation with the client's complaints where possible
- Use questions to clarify results and gain further information in a manner relevant to the client's needs and test results
- Base any decision to carry out laboratory tests on the integration of previously obtained clinical data and history
- Adhere to the protocol required by the agency in ordering tests
- Allow adequate time during consultation to gather critical information
- Identify and minimise factors that may interfere with the information gathering process
- Identify, establish and routinely observe essential requirements for the maintenance of clinical and practitioner hygiene
- Anticipate potential sensitivities of the client, adapt approach accordingly to take these into account and take steps to ensure the client's dignity are maintained at all times
- Make a comprehensive assessment of the client
- Identify signs of disease/condition and further observations according to naturopathic framework
- Elicit specific details of signs and symptoms of the presenting complaint/s
- Use other appropriate assessment techniques
- Accurately record all information in a systematic manner in accordance with clinic guidelines