Unit of Competency Mapping – Information for Teachers/Assessors – Information for Learners

HLTAHW007 Mapping and Delivery Guide
Undertake basic health assessments

Version 1.0
Issue Date: April 2024


Qualification -
Unit of Competency HLTAHW007 - Undertake basic health assessments
Description
Employability Skills
Learning Outcomes and Application This unit describes the knowledge and skills required to undertake a range of basic health assessments of Aboriginal and/or Torres Strait Islander clients, including infants, children and adults. This unit applies to Aboriginal and/or Torres Strait Islander Health Workers working as part, and under the supervision, of a multidisciplinary primary health care team to provide a range of primary health care services to Aboriginal and/or Torres Strait Islander clients and communities. 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.
Duration and Setting X weeks, nominally xx hours, delivered in a classroom/online/blended learning setting.

Skills must be demonstrated working:

in a health service or centre

as part of, and under the supervision of, a multidisciplinary primary health care team

with Aboriginal and/or Torres Strait Islander clients and communities.

In addition, simulations and scenarios must be used where the full range of contexts and situations cannot be provided in the workplace or may occur only rarely. These are situations relating to emergency or unplanned procedures where assessment in these circumstances would be unsafe or is impractical.

Simulated assessment environments must simulate the real-life working environment where these skills and knowledge would be performed, with all the relevant equipment and resources of that working environment.

Assessors must satisfy the Standards for Registered Training Organisations (RTOs) 2015/AQTF mandatory competency requirements for assessors.

Assessment must be undertaken by a workplace assessor who has expertise in this unit of competency and who is:

an Aboriginal and/or Torres Strait Islander Health Worker

or:

accompanied by an Aboriginal and/or Torres Strait Islander person who is a recognised member of the community with experience in primary health care.
Prerequisites/co-requisites
Competency Field
Development and validation strategy and guide for assessors and learners Student Learning Resources Handouts
Activities 		Slides
PPT 		Assessment 1 Assessment 2 Assessment 3 Assessment 4
Elements of Competency Performance Criteria              
Element: Elements define the essential outcomes.
       
Element: Obtain client information
  • Establish a relationship of trust with the client by demonstrating and respecting confidentiality
  • Use effective, culturally appropriate and safe communication to gain information from the client and/or significant others about general health, chronic conditions and specific presenting problems including any medications being taken
  • Access available documentation and written sources of information in relation to client’s health
  • Consult relevant allied health professionals about client’s health
  • Accurately record client information on client file according to organisation procedures and policies
       
Element: Perform basic physical examination
  • Explain the purpose and procedures involved in the examination to the client using culturally appropriate and safe communication skills
  • Confirm client understanding and gain client consent to the examination
  • Consider and respect Aboriginal and/or Torres Strait Islander community values, beliefs and gender roles when undertaking examination
  • Conduct examination according to organisation procedures and policies, standard infection control and workplace health and safety requirements
  • Accurately record measurements and findings and identify any significant variation from normal ranges according to organisational procedures
  • Identify non-clinical factors potentially responsible for significant variations identified and repeat assessments as required
  • Use, maintain and regularly clean medical equipment according to organisational procedures, standard infection control and workplace health and safety requirements
       
Element: Summarise and present findings
  • Accurately document client history and examination findings in the client’s file in accordance with organisational policies and procedures
  • Present and discuss client history and findings of physical examination with primary health care team according to organisational policies and procedures
  • Identify common, uncomplicated health conditions based on history, physical examination and available information about presenting problem
  • Recognise and assess self-management issues for clients with chronic conditions with primary health care team
  • Promptly inform senior health staff about serious or potentially serious health problems including chronic conditions, according to organisational procedures and policies
  • Identify and confirm with supervisor issues arising out of examination requiring mandatory notification
  • Report notifiable diseases identified to supervisor and/or an appropriate authority in line with jurisdictional requirements
       
Element: Support client’s physical wellbeing
  • Explain findings of physical examination to client in a culturally appropriate and safe manner according to organisation policies and procedures
  • Support client to improve and maintain health through a self-care approach and provide brief intervention as required
  • Discuss with the client and/or significant others any identified barriers and options to self care for clients with chronic conditions
  • Check for client understanding of information and encourage client to ask questions about health care
       
Element: Support client’s physical wellbeing
  • Explain findings of physical examination to client in a culturally appropriate and safe manner according to organisation policies and procedures
  • Support client to improve and maintain health through a self-care approach and provide brief intervention as required
  • Discuss with the client and/or significant others any identified barriers and options to self care for clients with chronic conditions
  • Check for client understanding of information and encourage client to ask questions about health care
       


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 specify the level of performance needed to demonstrate achievement of the element.

1. Obtain client information

1.1 Establish a relationship of trust with the client by demonstrating and respecting confidentiality

1.2 Use effective, culturally appropriate and safe communication to gain information from the client and/or significant others about general health, chronic conditions and specific presenting problems including any medications being taken

1.3 Access available documentation and written sources of information in relation to client’s health

1.4 Consult relevant allied health professionals about client’s health

1.5 Accurately record client information on client file according to organisation procedures and policies

2. Perform basic physical examination

2.1 Explain the purpose and procedures involved in the examination to the client using culturally appropriate and safe communication skills

2.2 Confirm client understanding and gain client consent to the examination

2.3 Consider and respect Aboriginal and/or Torres Strait Islander community values, beliefs and gender roles when undertaking examination

2.4 Conduct examination according to organisation procedures and policies, standard infection control and workplace health and safety requirements

2.5 Accurately record measurements and findings and identify any significant variation from normal ranges according to organisational procedures

2.6 Identify non-clinical factors potentially responsible for significant variations identified and repeat assessments as required

2.7 Use, maintain and regularly clean medical equipment according to organisational procedures, standard infection control and workplace health and safety requirements

3. Summarise and present findings

3.1 Accurately document client history and examination findings in the client’s file in accordance with organisational policies and procedures

3.2 Present and discuss client history and findings of physical examination with primary health care team according to organisational policies and procedures

3.3 Identify common, uncomplicated health conditions based on history, physical examination and available information about presenting problem

3.4 Recognise and assess self-management issues for clients with chronic conditions with primary health care team

3.5 Promptly inform senior health staff about serious or potentially serious health problems including chronic conditions, according to organisational procedures and policies

3.6 Identify and confirm with supervisor issues arising out of examination requiring mandatory notification

3.7 Report notifiable diseases identified to supervisor and/or an appropriate authority in line with jurisdictional requirements

4. Support client’s physical wellbeing

4.1 Explain findings of physical examination to client in a culturally appropriate and safe manner according to organisation policies and procedures

4.2 Support client to improve and maintain health through a self-care approach and provide brief intervention as required

4.3 Discuss with the client and/or significant others any identified barriers and options to self care for clients with chronic conditions

4.4 Check for client understanding of information and encourage client to ask questions about health care

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:

worked with at least five Aboriginal and/or Torres Strait Islander clients, including infants, adults and children to:

- conduct a health assessment of each client by:

o using a structured approach to assessment

o taking and recording relevant details of client’s history and current state, including body language

o observing and assessing client’s health in line with guidance

o using correct procedures and protocols to examine common client presentations

o using medical equipment correctly

o taking standard precautions for infection control

o summarising and reporting findings in line with organisation procedures and protocols

- interpret the outcomes of the assessment of each client by:

o identifying any significant variations from normal range of assessment outcomes for each client

o identifying and acting upon situations requiring urgent action according to organisation procedures

o recognising common uncomplicated health conditions from clinical features of each client

- used effective and culturally appropriate and safe communication and interaction with each client and/or significant others, including:

o eliciting relevant information from client or documents

o clearly explaining examination procedures and protocols to client

o making appropriate referrals

- recorded all findings in accordance with organisational procedures and policies with adherence to client confidentiality.

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:

organisational policies and procedures and legislation or regulations relating to:

- client confidentiality

- referral, including various levels of urgency

- mandatory reporting

- notifiable communicable diseases

- limits of own ability and authority

infection control and workplace health and safety procedures

knowledge of anatomy and physiology to identify major body systems, relevant organs and their functions, including:

- cardiovascular system (including heart, arteries and veins)

- respiratory system (including lungs, nose, mouth, throat)

- senses (including sight, hearing, smell, touch, taste and equilibrium)

- skin and integumentary system (including skin layers, hair and nails)

- digestive and gastrointestinal system (including stomach, intestines, bowel)

- nervous system (including brain and nerves)

- circulatory system (including arteries, veins)

- genitourinary system (including male and female genital and reproductive systems)

- endocrine system (including glands and hormones)

- musculoskeletal system (skull, skeleton, muscles, body tissue)

common conditions and presenting problems associated with major body systems and relevant organs, including chronic conditions

acute chronic conditions impacting on Aboriginal and/or Torres Strait Islander clients and communities, including:

- cardiovascular disease

- diabetes

- cancer

- chronic respiratory disease

- chronic kidney disease

- asthma

- arthritis

features of chronic illness, including:

- complex causality

- multiple risk factors

- long latency periods

- a prolonged course of illness

- functional impairment or disability

determinants of chronic conditions, including:

- smoking

- physical inactivity

- nutrition

- alcohol intake

- use of illicit drugs

- obesity

purpose, procedures and equipment involved in the following examinations, including:

- clinical hand wash

- external physical observations

- adult and paediatric methods for measuring:

o temperature

o pulse and respiration

o blood pressure

o blood glucose level

o haemoglobin

o weight and height

o length

o head and waist circumference

o visual acuity and ear examination

o peak expiratory flow rate (peak flow meter)

o INR (a test for blood clotting)

o glycohaemoglobin

o spirometry (measuring lung function)

o ECG (to detect cardiac abnormalities)

‘normal’ range of outcomes of physical assessments

non-clinical reasons for significant variation from ‘normal’ range of outcomes

common over-the-counter and prescribed medicines used within the community and their general purposes

basic knowledge relating to pregnancy and birthing, including:

- basic mechanics of pregnancy and birthing

- impact of smoking and alcohol in pregnancy

- impact of chronic conditions on pregnancy and birthing.

Submission Requirements

List each assessment task's title, type (eg project, observation/demonstration, essay, assignment, 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 specify the level of performance needed to demonstrate achievement of the element.

1. Obtain client information

1.1 Establish a relationship of trust with the client by demonstrating and respecting confidentiality

1.2 Use effective, culturally appropriate and safe communication to gain information from the client and/or significant others about general health, chronic conditions and specific presenting problems including any medications being taken

1.3 Access available documentation and written sources of information in relation to client’s health

1.4 Consult relevant allied health professionals about client’s health

1.5 Accurately record client information on client file according to organisation procedures and policies

2. Perform basic physical examination

2.1 Explain the purpose and procedures involved in the examination to the client using culturally appropriate and safe communication skills

2.2 Confirm client understanding and gain client consent to the examination

2.3 Consider and respect Aboriginal and/or Torres Strait Islander community values, beliefs and gender roles when undertaking examination

2.4 Conduct examination according to organisation procedures and policies, standard infection control and workplace health and safety requirements

2.5 Accurately record measurements and findings and identify any significant variation from normal ranges according to organisational procedures

2.6 Identify non-clinical factors potentially responsible for significant variations identified and repeat assessments as required

2.7 Use, maintain and regularly clean medical equipment according to organisational procedures, standard infection control and workplace health and safety requirements

3. Summarise and present findings

3.1 Accurately document client history and examination findings in the client’s file in accordance with organisational policies and procedures

3.2 Present and discuss client history and findings of physical examination with primary health care team according to organisational policies and procedures

3.3 Identify common, uncomplicated health conditions based on history, physical examination and available information about presenting problem

3.4 Recognise and assess self-management issues for clients with chronic conditions with primary health care team

3.5 Promptly inform senior health staff about serious or potentially serious health problems including chronic conditions, according to organisational procedures and policies

3.6 Identify and confirm with supervisor issues arising out of examination requiring mandatory notification

3.7 Report notifiable diseases identified to supervisor and/or an appropriate authority in line with jurisdictional requirements

4. Support client’s physical wellbeing

4.1 Explain findings of physical examination to client in a culturally appropriate and safe manner according to organisation policies and procedures

4.2 Support client to improve and maintain health through a self-care approach and provide brief intervention as required

4.3 Discuss with the client and/or significant others any identified barriers and options to self care for clients with chronic conditions

4.4 Check for client understanding of information and encourage client to ask questions about health care

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
 
Establish a relationship of trust with the client by demonstrating and respecting confidentiality 
Use effective, culturally appropriate and safe communication to gain information from the client and/or significant others about general health, chronic conditions and specific presenting problems including any medications being taken 
Access available documentation and written sources of information in relation to client’s health 
Consult relevant allied health professionals about client’s health 
Accurately record client information on client file according to organisation procedures and policies 
Explain the purpose and procedures involved in the examination to the client using culturally appropriate and safe communication skills 
Confirm client understanding and gain client consent to the examination 
Consider and respect Aboriginal and/or Torres Strait Islander community values, beliefs and gender roles when undertaking examination 
Conduct examination according to organisation procedures and policies, standard infection control and workplace health and safety requirements 
Accurately record measurements and findings and identify any significant variation from normal ranges according to organisational procedures 
Identify non-clinical factors potentially responsible for significant variations identified and repeat assessments as required 
Use, maintain and regularly clean medical equipment according to organisational procedures, standard infection control and workplace health and safety requirements 
Accurately document client history and examination findings in the client’s file in accordance with organisational policies and procedures 
Present and discuss client history and findings of physical examination with primary health care team according to organisational policies and procedures 
Identify common, uncomplicated health conditions based on history, physical examination and available information about presenting problem 
Recognise and assess self-management issues for clients with chronic conditions with primary health care team 
Promptly inform senior health staff about serious or potentially serious health problems including chronic conditions, according to organisational procedures and policies 
Identify and confirm with supervisor issues arising out of examination requiring mandatory notification 
Report notifiable diseases identified to supervisor and/or an appropriate authority in line with jurisdictional requirements 
Explain findings of physical examination to client in a culturally appropriate and safe manner according to organisation policies and procedures 
Support client to improve and maintain health through a self-care approach and provide brief intervention as required 
Discuss with the client and/or significant others any identified barriers and options to self care for clients with chronic conditions 
Check for client understanding of information and encourage client to ask questions about health care 
Explain findings of physical examination to client in a culturally appropriate and safe manner according to organisation policies and procedures 
Support client to improve and maintain health through a self-care approach and provide brief intervention as required 
Discuss with the client and/or significant others any identified barriers and options to self care for clients with chronic conditions 
Check for client understanding of information and encourage client to ask questions about health care 

Forms

Assessment Cover Sheet

HLTAHW007 - Undertake basic health assessments
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

HLTAHW007 - Undertake basic health assessments

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: