This unit of competency is applicable to Australian Defence Force (ADF) Health Care Providers |
Not Applicable
ELEMENT | PERFORMANCE CRITERIA |
1. Prepare for clinical assessment | 1.1 Assess environment for suitability to conduct a clinical assessment 1.2 Select required equipment, consumables and documentation, check for serviceability and arrange for use 1.3 Review relevant client history 1.4 Use personal protective equipment as required |
2. Prepare client for clinical assessment | 2.1 Explain clinical assessment clearly and simply to the client 2.2 Give client is given the opportunity to ask questions and discuss concerns 2.3 Gain informed consent from client in accordance with clinical guidelines, organisation policies and procedures 2.4 Assure and maintain confidentiality of client information |
3. Obtain and record a medical history and client profile | 3.1 Ensure client is comfortable and positioned in a manner to avoid distractions 3.2 Interview client to gather and convey information 3.3 Obtain and record medical history and client profile according to clinical guidelines, organisation policies and procedures |
4. Conduct a physical examination | 4.1 Follow personal hygiene and infection control procedures 4.2 Measure and record vital signs in accordance with clinical guidelines, organisation policies and procedures 4.3 Conduct examination using appropriate physical examination techniques according to clinical guidelines, organisation policies and procedures 4.4 Record examination outcomes in accordance with clinical guidelines, organisation policies and procedures |
5. Make a clinical assessment | 5.1 Make clinical assessment according to applied clinical reasoning and organisation policies and procedures 5.2 Determine need for referral for extended physical examination and/or further diagnostic procedures 5.3 Use information gathered through the clinical assessment to the develop treatment plan 5.4 Arrange appropriate referral as required |
6. Conclude clinical assessment | 6.1 Explain clinical assessment findings clearly and simply to the client 6.2 Record clinical findings in a way that can be interpreted readily by others and according to clinic guidelines, organisation policies and procedures 6.3 Clean and/or dispose of equipment and consumables in accordance with manufacturers' requirements and infection control policy 6.4 Store equipment and consumables in accordance with organisation policy and procedures |
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 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 |
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 |
Not Applicable
This unit contains Employability Skills |
Not Applicable