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

HLTAHW304B Mapping and Delivery Guide
Undertake basic health assessments

Version 1.0
Issue Date: March 2024


Qualification -
Unit of Competency HLTAHW304B - Undertake basic health assessments
Description This unit deals with the skills and knowledge required to undertake a range of basic health assessments as a supervised member of a multi-disciplinary team working with Aboriginal and/or Torres Strait Islander communities
Employability Skills This unit contains Employability Skills
Learning Outcomes and Application This unit may be applied by those working individually (e.g. in isolated practice) or as part of a team (e.g. in a clinic or hospital)All work is to be carried out with guidance from and under supervision of a medical practitioner or other appropriate health care professionalIt is imperative that cultural issues, including gender and kinship issues, are respected in the delivery, assessment and application of this competency unit
Duration and Setting X weeks, nominally xx hours, delivered in a classroom/online/blended learning setting.
Prerequisites/co-requisites Not Applicable
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: Obtain client information
  • Seek to establish a relationship of trust with the client, through active promotion of and strict adherence to confidentiality
  • Obtain an accurate history from the client, using available information from verbal, written and non-verbal sources
  • Seek health related information from the client, their family and/or carer(s) and relevant community members
  • Consult relevant allied professionals and available documentation in relation to the health of the client
  • Identify self-management issues and assess and record these for clients with chronic conditions
       
Element: Undertake basic physical examination
  • Obtain permission from the client to conduct physical examination
  • Consider and respect Aboriginal or Torres Strait Islander community values, beliefs and gender roles when undertaking physical examination
  • Measure vital signs and identify significant variation from normal
  • Undertake physical examinations in line with organisation procedures and protocols
  • Conduct physical examinations in accordance with standard infection control and occupational health and safety requirements
  • Identify non-clinical factors potentially responsible for any significant variation from normal and make repeat assessments, if required
  • Use, maintain and regularly clean medical equipment in accordance with generic OH&S and Infection Control guidelines and organisation policies
  • Provide clients with information about each examination/test to be undertaken and the rationale for its use
       
Element: Summarise and present findings
  • Accurately document client history and examination findings in the client's file in accordance with organisation policies and procedures
  • Present client history and findings of physical examination as determined by organisation policies and procedures
  • Identify common uncomplicated health conditions based on history, physical examination and available information about presenting problem
  • Promptly refer to senior health staff for advice about serious or potentially serious health problems as determined in organisation protocols
  • Provide client with information about findings of physical examination in line with organisation policies and procedures
  • Provide client with information relevant to promoting and maintaining health in a way they understand readily
  • Check client understanding of information through appropriate questioning
  • Provide health information to the client in appropriate language, supported by visual and other aids as required
  • Support clients to take a self-care approach to health in line with individual needs and organisation and community requirements
  • Identify issues requiring mandatory notification and report to supervisor and/or an appropriate authority
  • Report notifiable diseases identified to supervisor and/or an appropriate authority in line with jurisdictional requirements
  • Identify key barriers to management or self-management of chronic diseases as clarified with client, family and carer
       


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.

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 and/or 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 him/herself

or:

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 and/or 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


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.

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)

temperature

pulse rate

respiratory and peak flow rates

Common conditions and associated presenting problems, including:

respiratory conditions

genito-urinary 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 (e.g. premature labour, bleeding, high BP)

continued ...

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:

crowding

clean water

sanitation

food contamination

insect vectors

Basic nature of common diseases, including:

cardiovascular diseases

rheumatic fever and rheumatic heart disease

diabetes

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

Important elements of self-management and supporting client self-management of chronic conditions, including an understanding of:

attributes of self-management

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 client's history, including body language

observe and assess client's 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 non-urgent 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 self-management 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

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

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

Allergies

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:

Thermometers

Stethoscopes

Peak expiratory flow rate meters

Eye scope (ophthalmoscope)

Scales

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:

Temperature

Pulse

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

Constipation

Uncomplicated gastroenteritis

Impetigo (school sores) and boils

Scabies

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

urinalysis

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:
(continued)

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

E-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

spirometry

oximetry

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.

Identify:

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

Anxiety

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

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 a relationship of trust with the client, through active promotion of and strict adherence to confidentiality 
Obtain an accurate history from the client, using available information from verbal, written and non-verbal sources 
Seek health related information from the client, their family and/or carer(s) and relevant community members 
Consult relevant allied professionals and available documentation in relation to the health of the client 
Identify self-management issues and assess and record these for clients with chronic conditions 
Obtain permission from the client to conduct physical examination 
Consider and respect Aboriginal or Torres Strait Islander community values, beliefs and gender roles when undertaking physical examination 
Measure vital signs and identify significant variation from normal 
Undertake physical examinations in line with organisation procedures and protocols 
Conduct physical examinations in accordance with standard infection control and occupational health and safety requirements 
Identify non-clinical factors potentially responsible for any significant variation from normal and make repeat assessments, if required 
Use, maintain and regularly clean medical equipment in accordance with generic OH&S and Infection Control guidelines and organisation policies 
Provide clients with information about each examination/test to be undertaken and the rationale for its use 
Accurately document client history and examination findings in the client's file in accordance with organisation policies and procedures 
Present client history and findings of physical examination as determined by organisation policies and procedures 
Identify common uncomplicated health conditions based on history, physical examination and available information about presenting problem 
Promptly refer to senior health staff for advice about serious or potentially serious health problems as determined in organisation protocols 
Provide client with information about findings of physical examination in line with organisation policies and procedures 
Provide client with information relevant to promoting and maintaining health in a way they understand readily 
Check client understanding of information through appropriate questioning 
Provide health information to the client in appropriate language, supported by visual and other aids as required 
Support clients to take a self-care approach to health in line with individual needs and organisation and community requirements 
Identify issues requiring mandatory notification and report to supervisor and/or an appropriate authority 
Report notifiable diseases identified to supervisor and/or an appropriate authority in line with jurisdictional requirements 
Identify key barriers to management or self-management of chronic diseases as clarified with client, family and carer 

Forms

Assessment Cover Sheet

HLTAHW304B - Undertake basic health assessments
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Assessment Record Sheet

HLTAHW304B - Undertake basic health assessments

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Assessment task 1: [title] Result: Competent Not yet competent

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