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.
Elements and Performance Criteria
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 |
Evidence of Performance
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.
Evidence of 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:
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.
Assessment Conditions
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.
Foundation Skills
The Foundation Skills describe those required skills (language, literacy, numeracy and employment skills) that are essentialto performance. |
Foundation skills essential to performance are explicit in the performance criteria of this unit of competency. |