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

HLTAHW016 Mapping and Delivery Guide
Assess clients physical wellbeing

Version 1.0
Issue Date: April 2024


Qualification -
Unit of Competency HLTAHW016 - Assess clients physical wellbeing
Description
Employability Skills
Learning Outcomes and Application This unit describes the skills and knowledge required to initiate, undertake and interpret findings from a range of clinical assessments, tests and procedures to determine the physical wellbeing of a client. Findings of these assessments will be used as the basis of a health care plan – the skills and knowledge to plan, implement and monitor a health care plan are detailed in HLTAHW018 Plan, implement and monitor health care plan in a primary health care context. This unit applies to those Aboriginal and/or Torres Strait Islander Health Workers providing 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 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.

This may include medical equipment including but not limited to haemoglobin meter, tape measure, sphygmomanometer, scales, thermometers, glucometer, peak expiratory flow rate meters.

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: Initiate health assessment
  • Seek to establish trust with the client, through active promotion of and strict adherence to confidentiality
  • Obtain client’s history using effective, culturally appropriate and safe communication skills
  • Seek additional health-related information from the client’s family and/or carer(s) and relevant community members with the client’s consent
  • Consult relevant allied professionals and available documentation in relation to the health of the client
  • Document all information about the client in accordance with organisational procedures and policies
       
Element: Assess client’s physical health
  • Explain the process and rationale of each examination and test to the client
  • Perform physical and clinical assessments in line with organisational policies and procedures and with respect for community values, beliefs and gender roles
  • Measure vital signs and identify significant variation from normal ranges and refer to senior staff member as required
  • Use correct procedures and take precautions to collect and send specimens for pathology testing
  • Accurately record all outcomes of assessments in accordance with organisational procedures and policies
  • Identify non-clinical factors potentially responsible for significant variations from normal ranges and make repeat assessments
       
Element: Interpret and confirm health assessment findings
  • Accurately identify a range of signs and symptoms of health conditions
  • Recognise signs and symptoms of potentially serious underlying conditions and refer to senior health staff for advice
  • Interpret the significance of health assessment findings in the context of the holistic health of the client
       
Element: Identify any significant variations from normal range on the basis of health assessment data
  • Consult other team members to confirm interpretations and clarify implications and significance of findings
  • Seek assistance when findings are unclear or outside limits of own authority
  • Report notifiable diseases identified to supervisor and/or an appropriate authority, in line with jurisdictional requirements
  • Initiate action in relation to any issues requiring mandatory reporting according to procedural and legislative requirements
  • Accurately document client history and examination findings in client’s file
       
Element: Summarise and present findings
  • Provide client with information about findings of physical examination
  • Check client understanding of information through appropriate questioning
  • Provide client with information relevant to promoting and maintaining their health in a way they readily understand
  • Support client to take a self-care approach to health in line with individual needs and organisational and community requirements
  • Document and refer as necessary all discussions with client and/or significant others in client file according to organisational procedures and policies
       
Element: Assess client’s physical health
  • Explain the process and rationale of each examination and test to the client
  • Perform physical and clinical assessments in line with organisational policies and procedures and with respect for community values, beliefs and gender roles
  • Measure vital signs and identify significant variation from normal ranges and refer to senior staff member as required
  • Use correct procedures and take precautions to collect and send specimens for pathology testing
  • Accurately record all outcomes of assessments in accordance with organisational procedures and policies
  • Identify non-clinical factors potentially responsible for significant variations from normal ranges and make repeat assessments
       


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. Initiate health assessment

1.1 Seek to establish trust with the client, through active promotion of and strict adherence to confidentiality

1.2 Obtain client’s history using effective, culturally appropriate and safe communication skills

1.3 Seek additional health-related information from the client’s family and/or carer(s) and relevant community members with the client’s consent

1.4 Consult relevant allied professionals and available documentation in relation to the health of the client

1.5 Document all information about the client in accordance with organisational procedures and policies

2. Assess client’s physical health

2.1 Explain the process and rationale of each examination and test to the client

2.2 Perform physical and clinical assessments in line with organisational policies and procedures and with respect for community values, beliefs and gender roles

2.3 Measure vital signs and identify significant variation from normal ranges and refer to senior staff member as required

2.4 Use correct procedures and take precautions to collect and send specimens for pathology testing

2.5 Accurately record all outcomes of assessments in accordance with organisational procedures and policies

2.6 Identify non-clinical factors potentially responsible for significant variations from normal ranges and make repeat assessments

3. Interpret and confirm health assessment findings

3.1 Accurately identify a range of signs and symptoms of health conditions

3.2 Recognise signs and symptoms of potentially serious underlying conditions and refer to senior health staff for advice

3.3 Interpret the significance of health assessment findings in the context of the holistic health of the client

3.4Identify any significant variations from normal range on the basis of health assessment data

3.5 Consult other team members to confirm interpretations and clarify implications and significance of findings

3.6 Seek assistance when findings are unclear or outside limits of own authority

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

3.8 Initiate action in relation to any issues requiring mandatory reporting according to procedural and legislative requirements

3.9 Accurately document client history and examination findings in client’s file

4. Summarise and present findings

4.1 Provide client with information about findings of physical examination

4.2 Check client understanding of information through appropriate questioning

4.3 Provide client with information relevant to promoting and maintaining their health in a way they readily understand

4.4 Support client to take a self-care approach to health in line with individual needs and organisational and community requirements

4.5 Document and refer as necessary all discussions with client and/or significant others in client file according to organisational procedures and policies

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:

assessed and monitored the physical wellbeing of at least five Aboriginal and/or Torres Strait Islander adults and children by:

- establishing a relationship of trust with clients and significant others

- taking a detailed history of the client

- explaining assessment methods and procedures to client and/or significant others

- observing and assessing client’s health, using appropriate tests and medical instrumentation

- recording observations

- questioning, assessing and monitoring client’s health status, issues and needs

- reviewing effectiveness of health care strategies and making appropriate revisions, taking prior history into consideration

- summarising and presenting findings in line with client needs and workplace requirements

- maintaining client records and upholding client confidentiality

- communicating with client’s family and/or significant others as required

- gaining informed consent to conduct assessment

- taking, considering and recording relevant details of client’s history (including body language)

- complying with and enforcing infection control guidelines

- using a structured approach to assessment

- interpreting common pathology tests

- taking full responsibility for assessment findings.

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, and follow-up of client

- mandatory reporting

- notifiable communicable diseases

- limits of own ability and authority

- reporting procedures

- documentation

key elements of comprehensive and accurate physical, social/emotional and mental health assessment

anatomy/physiology and associated microbiology, pathophysiology (disease processes) and pharmacology including:

- respiratory system

- circulatory system

- integumentary system

- digestive system

- genitourinary system

- endocrine system

- musculoskeletal system

- nervous system

- reproductive systems

pathophysiology associated with these systems, including:

- acute chronic condition and conditions associated with a specific body system

- injuries

- wounds

- arthritis

- inflammation

- impact of alcohol and drugs

pharmacology to address pathophysiology, including:

- medications and forms of administration

- antibiotics

- analgesics

- contraindications

- complications

- psychiatric medications

- oral hypoglycaemics

- insulin

procedures for health tests and ‘normal’ range of test outcomes, including:

- blood pressure (for adults and children)

- temperature

- pulse rate

- respiratory and peak flow rates

- height and weight

- components of urine

- near vision and pinhole visual acuity testing

visual examination of eye and ear

blood glucose (sugar) and haemoglobin levels

in relation to cardiovascular diseases:

- the concept of ‘cardiovascular risk factors’, the significance of an individual having multiple risk factors and the concept of ‘high absolute risk’

- the importance of reduction of saturated fats and sugar-sweetened soft drinks, increased physical activity and smoking cessation in reducing the risk of heart and kidney disease in Aboriginal and/or Torres Strait Islander populations

in relation to diabetes mellitus:

- basic pathophysiology of type II contrasted with type I diabetes mellitus

- complications of diabetes (including heart disease and stroke; renal failure; retinal damage and blindness; nerve damage and infection resulting in amputation; impotence)

- the main elements of the ‘diabetes check up’

- the procedure for taking retinal photographs

- basic anatomical features and abnormalities on a retinal photograph

- the content of client education for diabetes covering diet, physical activity, foot-care, and use of diabetes medicines

in relation to chronic renal disease:

- basic pathophysiology of chronic renal failure (causes, body systems affected, natural history)

- factors which may worsen or accelerate renal failure (including: high blood pressure, anti-inflammatory drugs, poor diabetes control, dehydration, high protein diet)

- clinical features of advanced renal failure

- the importance of early detection of renal disease in efforts to defer or prevent end-stage renal failure

- options for treatment of end-stage renal failure (haemodialysis, chronic ambulatory peritoneal dialysis, transplant).

familiarity with a range of other common chronic conditions in Aboriginal and/or Torres Strait Islander populations:

- chronic liver disease – causes, clinical features and principles of management (including hepatitis B, hepatitis C, alcoholic liver disease and cirrhosis)

- chronic obstructive lung disease, relationship to smoking and principles of management

basic nature, management and associated risk factors for common diseases

commonly (including complete blood tests and urine analysis) and specifically requested pathology tests and the correct methods of collection, storage and transport of specimens

the clinical significance of abnormal findings on pathology tests with particular reference to use of medicines

knowledge of care planning and self-management support tools

relevant criteria for evaluation of effectiveness of care plan

features of chronic illness, including:

- complex causality

- multiple risk factors

- long latency periods

- a prolonged course of illness

- functional impairment or disability

specific chronic conditions affecting Aboriginal and/or Torres Strait Islander clients and communities, including:

- cardiovascular disease

- diabetes

- cancer

- chronic respiratory disease

- chronic kidney disease

- asthma

- arthritis

- oral disease

determinants of chronic conditions, including:

- smoking

- physical activity

- nutrition

- alcohol intake

- use of illicit drugs

- obesity, weight and waist circumference

- unsafe sexual practices

- genetic factors

linkages between conditions such as diabetes and eye health, nutrition and hearing, etc.

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. Initiate health assessment

1.1 Seek to establish trust with the client, through active promotion of and strict adherence to confidentiality

1.2 Obtain client’s history using effective, culturally appropriate and safe communication skills

1.3 Seek additional health-related information from the client’s family and/or carer(s) and relevant community members with the client’s consent

1.4 Consult relevant allied professionals and available documentation in relation to the health of the client

1.5 Document all information about the client in accordance with organisational procedures and policies

2. Assess client’s physical health

2.1 Explain the process and rationale of each examination and test to the client

2.2 Perform physical and clinical assessments in line with organisational policies and procedures and with respect for community values, beliefs and gender roles

2.3 Measure vital signs and identify significant variation from normal ranges and refer to senior staff member as required

2.4 Use correct procedures and take precautions to collect and send specimens for pathology testing

2.5 Accurately record all outcomes of assessments in accordance with organisational procedures and policies

2.6 Identify non-clinical factors potentially responsible for significant variations from normal ranges and make repeat assessments

3. Interpret and confirm health assessment findings

3.1 Accurately identify a range of signs and symptoms of health conditions

3.2 Recognise signs and symptoms of potentially serious underlying conditions and refer to senior health staff for advice

3.3 Interpret the significance of health assessment findings in the context of the holistic health of the client

3.4Identify any significant variations from normal range on the basis of health assessment data

3.5 Consult other team members to confirm interpretations and clarify implications and significance of findings

3.6 Seek assistance when findings are unclear or outside limits of own authority

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

3.8 Initiate action in relation to any issues requiring mandatory reporting according to procedural and legislative requirements

3.9 Accurately document client history and examination findings in client’s file

4. Summarise and present findings

4.1 Provide client with information about findings of physical examination

4.2 Check client understanding of information through appropriate questioning

4.3 Provide client with information relevant to promoting and maintaining their health in a way they readily understand

4.4 Support client to take a self-care approach to health in line with individual needs and organisational and community requirements

4.5 Document and refer as necessary all discussions with client and/or significant others in client file according to organisational procedures and policies

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
 
Seek to establish trust with the client, through active promotion of and strict adherence to confidentiality 
Obtain client’s history using effective, culturally appropriate and safe communication skills 
Seek additional health-related information from the client’s family and/or carer(s) and relevant community members with the client’s consent 
Consult relevant allied professionals and available documentation in relation to the health of the client 
Document all information about the client in accordance with organisational procedures and policies 
Explain the process and rationale of each examination and test to the client 
Perform physical and clinical assessments in line with organisational policies and procedures and with respect for community values, beliefs and gender roles 
Measure vital signs and identify significant variation from normal ranges and refer to senior staff member as required 
Use correct procedures and take precautions to collect and send specimens for pathology testing 
Accurately record all outcomes of assessments in accordance with organisational procedures and policies 
Identify non-clinical factors potentially responsible for significant variations from normal ranges and make repeat assessments 
Accurately identify a range of signs and symptoms of health conditions 
Recognise signs and symptoms of potentially serious underlying conditions and refer to senior health staff for advice 
Interpret the significance of health assessment findings in the context of the holistic health of the client 
Consult other team members to confirm interpretations and clarify implications and significance of findings 
Seek assistance when findings are unclear or outside limits of own authority 
Report notifiable diseases identified to supervisor and/or an appropriate authority, in line with jurisdictional requirements 
Initiate action in relation to any issues requiring mandatory reporting according to procedural and legislative requirements 
Accurately document client history and examination findings in client’s file 
Provide client with information about findings of physical examination 
Check client understanding of information through appropriate questioning 
Provide client with information relevant to promoting and maintaining their health in a way they readily understand 
Support client to take a self-care approach to health in line with individual needs and organisational and community requirements 
Document and refer as necessary all discussions with client and/or significant others in client file according to organisational procedures and policies 
Explain the process and rationale of each examination and test to the client 
Perform physical and clinical assessments in line with organisational policies and procedures and with respect for community values, beliefs and gender roles 
Measure vital signs and identify significant variation from normal ranges and refer to senior staff member as required 
Use correct procedures and take precautions to collect and send specimens for pathology testing 
Accurately record all outcomes of assessments in accordance with organisational procedures and policies 
Identify non-clinical factors potentially responsible for significant variations from normal ranges and make repeat assessments 

Forms

Assessment Cover Sheet

HLTAHW016 - Assess clients physical wellbeing
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

HLTAHW016 - Assess clients physical wellbeing

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: