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

HLTDEFHC403B Mapping and Delivery Guide
Conduct a clinical assessment

Version 1.0
Issue Date: May 2024


Qualification -
Unit of Competency HLTDEFHC403B - Conduct a clinical assessment
Description This unit covers the competency required to conduct a clinical assessment of a client, including obtaining and recording a medical history, conducting a physical examination and making and recording a clinical assessment of the client
Employability Skills This unit contains Employability Skills
Learning Outcomes and Application This unit of competency is applicable to Australian Defence Force (ADF) Health Care Providers
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: Prepare for clinical assessment
  • Assess environment for suitability to conduct a clinical assessment
  • Select required equipment, consumables and documentation, check for serviceability and arrange for use
  • Review relevant client history
  • Use personal protective equipment as required
       
Element: 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
       
Element: Obtain and record a medical history and client profile
  • Ensure client is comfortable and positioned in a manner to avoid distractions
  • Interview client to gather and convey information
  • Obtain and record medical history and client profile according to clinical guidelines, organisation policies and procedures
       
Element: 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
       
Element: 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
       
Element: 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
       


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 for assessment and evidence required to demonstrate this competency unit:

Assessment must confirm the ability to :

Resource implications

Assessment requires access to:

appropriate equipment

scenarios that reflect a range of clinical assessments that may be expected in the workplace

reference texts

local legal guidelines

Consistency in performance

Competency should be demonstrated over time with a range of clinical assessments that could be expected in the workplace

Context of assessment

Competency should be assessed in the workplace or in a simulated workplace

Access and equity considerations:

All workers in the health industry should be aware of access and equity issues in relation to their own area of work

All workers should develop their ability to work in a culturally diverse environment

In recognition of particular health issues facing Aboriginal and Torres Strait Islander communities, workers should be aware of cultural, historical and current issues impacting on health of Aboriginal and Torres Strait Islander people

Assessors and trainers must take into account relevant access and equity issues, in particular relating to factors impacting on health of Aboriginal and/or Torres Strait Islander clients and communities

Related units:

This unit should be assessed in conjunction with this unit:

HLTDEFHC408B Provide treatments for common conditions

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:

Clinic and legislative guidelines

Clinical anatomy and physiology relevant to performing the examination and to evaluating results of the clinical assessment

Clinical tools and resources

Disease processes and affecting factors for a range of common conditions

Environmental causes of disease

Ethical and legal implications of examination

Further testing procedures

Interview techniques

Monitoring and maintaining appropriate medical equipment

Pathophysiology and disease process and classification relevant to making a clinical assessment and interpreting the findings

Purpose, method and sequencing of physical examinations

Referral procedure and recommended referral options

Relationship between physical findings, clinical diagnosis and treatment

Terminology correct to discipline

Essential skills:

It is critical that the candidate demonstrate the ability to:

Accurately record information in a systematic manner in accordance with clinic guidelines

Employ effective communication techniques during the client interview process

Identify and record signs and symptoms of disease

Interpret and understand the significance of findings

Know own limitations in clinical diagnosis sufficient to safeguard the client

Measure blood pressure, respiration rate, pulse rate and body temperature

Obtain and record a detailed medical history

Obtain problem focused information by performing inspection, palpation, auscultation, percussion, appropriate manoeuvres using appropriate examination equipment

continued ...

Essential skills (contd):

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:

Accurately record information

Correctly monitor, clean and maintain equipment

Correctly dispose of waste and sharps in accordance with workplace policy and taking into account opportunities to address waste minimisation, environmental responsibility and sustainable practice issues

Discuss and observe treatment protocols

Read and interpret medical reports

Relate examination outcome to symptomatology

Relate to a range of people from a range of cultural, linguistic, social and ethnic backgrounds, and a range of physical and intellectual abilities

Relate results of the test to symptomatology

Use available resources and prioritise workload

Use clinical tools and resources including the following:

equipment for measuring height and weight

examination table

glucometer and disposable lancets devices

goggles/protective eyewear

goose-neck lamp or other light source

measuring tape

nasal speculum

ophthalmoscope

otoscope

peak flow meter and disposable mouth pieces

penlight

percussion (reflex) hammer

sphygmomanometer

stethoscope

thermometer

timing device

Use medical reference

Use appropriate medical terminology

Use, monitor and maintain appropriate medical equipment

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.

Environment assessment may include:

Adequate lighting

Health care practitioner's specified needs

Suitable climate

Suitable client privacy

Equipment and consumables may include:

Equipment for measuring height and weight

Examination table

Glucometer and disposable lancets devices

Goggles/protective eyewear

Goose-neck lamp or other light source

Measuring tape

Nasal speculum

Ophthalmoscope

Otoscope

Peak flow meter and disposable mouth pieces

Penlight

Percussion (reflex) hammer

Skin marking pencil

Sphygmomanometer

Stethoscope

Thermometer

Timing device

Alcohol cleansing wipes

Cotton-tipped swab

Disposable gloves

Examination gowns

Gauze squares

Half-sheet for draping

Hazard bags for infection control

Instrument cleaning supplies

Sharps containers

Tongue depressors

Visual acuity charts

Confidentiality of client information may be ensured by:

Adherence to Privacy Act

Information disclosed to an appropriate person consistent with the responsibility of this position

Legal and ethical requirements

Secure location for written records

Treatment room with privacy

Medical history and client profile may include:

Current health information including:

habits (alcohol, tobacco, drugs, caffeine)

current medication being taken

exercise, sleep and dietary patterns

Past health history (pertinent to presenting complaint) such as:

past general health

accidents and disabling injuries

major acute and chronic illnesses

past allergies

past medications

Client biographical information

Presenting complaint

Present health and illness status, such as:

client summary and usual health

onset of current condition

progression since onset

body location, quality, quantity of discomfort

alleviating or aggravating factors (environment)

disability assessment

Relevant family health history

Review of systems:

physical background

functional limitations

sociological circumstance (home, work, etc)

psychological integrity

Clinical guidelines, organisation policies and procedures may include:

ADF nursing procedure manual

ADF treatment protocols

Clinical standards (state and national)

Industry professional bodies

Industry standards (state and national)

Organisation policy directives

Privacy Act

Relevant Australian standards

Measuring vital signs may include:

Following standardised procedures for infection control

Measuring blood pressure, respiration and pulse rates, and temperature

Personal hygiene and infection control procedures may include:

Australian and state standards and legislation

Industry standards

Organisation procedures

Standard precautions such as hand washing procedures

Direct instructions from supervisor

Physical examination techniques include:

Appropriate manoeuvres

Use of examination equipment

Auscultation

Inspection

Palpation

Percussion

Applied clinical reasoning includes:

Collecting clinical data (interview, medical history, physical examination, clinical measurements)

Organising data (recognising key diagnostic data, validating data, clustering data into a clinical pattern)

Making the clinical assessment

Linking the assessment to the treatment plan

Need for referral may include:

Need for higher medical diagnostic information or procedures

Signs of notifiable disease

Suspected dangerous pathology

Unknown symptom complex or condition

Identified condition outside of own scope of management

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
Assess environment for suitability to conduct a clinical assessment 
Select required equipment, consumables and documentation, check for serviceability and arrange for use 
Review relevant client history 
Use personal protective equipment as required 
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 
Ensure client is comfortable and positioned in a manner to avoid distractions 
Interview client to gather and convey information 
Obtain and record medical history and client profile according to clinical guidelines, organisation policies and procedures 
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 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 
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 

Forms

Assessment Cover Sheet

HLTDEFHC403B - Conduct a clinical assessment
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

HLTDEFHC403B - Conduct a clinical assessment

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: