HLTHOM604C
Perform clinical screening examination and assessment

This unit of competency describes the skills and knowledge required to perform screening examination of vital signs and physical condition and to make a screening assessment of the clientProcedures are governed by the application of local legislation

Application

This unit applies to work in homœopathy


Prerequisites

Not Applicable


Elements and Performance Criteria

ELEMENT

PERFORMANCE CRITERIA

1. Observe client's vital signs

1.1 Observe client's demeanour and appearance

1.2 Organise examination

1.3 Communicate examination procedures to client

1.4 Undertake examination for vital signs

2. Conduct screening physical examination according to local legislative guidelines

2.1 Conduct screening examination when needed to ensure client safety and elicit signs of disease

2.2 Identify areas of investigation

2.3 Organise examination

2.4 Communicate examination procedures to client

2.5 Conduct examination using appropriate techniques, equipment and supplies

2.6 Conduct examination according to clinic guidelines, local regulation and legislative requirements

3. Make a screening assessment and refer for further examination

3.1 Conduct extended interview

3.2 Make a screening assessment to ensure client safety

3.3 Determine the need for referral for extended physical examination and/or further diagnostic procedures

3.4 Arrange referral as needed

4. Monitor and record findings

4.1 Record all findings and file in accordance with clinic guidelines

4.2 Monitor outcomes of referrals

4.3 Treat all documentation confidentially

5. Discuss outcomes of referral with the client

5.1 Discuss rationale of the medical diagnosis/prognosis with the client

5.2 Respond to client enquiries using language the client understands

5.3 Discuss referral and collaborative options with the client if necessary

Required Skills

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:

Anatomy and physiology relevant to evaluating results of the screening assessment

Basic nutritional requirements for the various ages and stages of life

Clinic and local legislative guidelines relevant to assessment techniques

Clinical anatomy and physiology relevant to performing the examination

Disease processes and affecting factors for a range of common diseases

Ethical and legal implications of enquiry and examination

Further testing procedures

Homœopathic tools and resources

Interview techniques

Normal anatomy in relation to diagnostic imaging procedures

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

Pathophysiology and disease process relevant to performing the examination

Referral procedure and recommended referral options

Relevant anatomy and pathophysiology to competently collect specimens and interpret results

Relevant medical equipment

Terminology correct to discipline

The environmental causes of disease

The mode of presentation of potentially fatal and emergency medical and surgical conditions

The practitioner's own limitations in clinical diagnosis and therapy sufficient to safeguard the client

The purpose, method and sequencing of screening physical examinations

The relationship between physical findings, clinical diagnosis and homœopathic prescribing

The relationship between physical findings, clinical diagnosis and homœopathic prescribing

The relationship between physical findings, diagnosis and homœopathic prescribing

Essential skills:

It is critical that the candidate demonstrate the ability 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

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

Address time management requirements during consultation

Communicate effectively to gain required information

Correctly dispose of waste and sharps in accordance with workplace policy

Correctly monitor, clean and maintain equipment

Demonstrate communication skills

Discuss and observe treatment protocols

Identify and record signs and symptoms of disease

Identify clinical signs of nutritional imbalance

Interpret and understand the significance of findings

Interpret medical test data such as urine, blood test data, faecal and biopsy reports

Obtain problem focused information by performing inspection, palpation, auscultation, percussion and appropriate manoeuvres

Read and interpret medical reports

Read and interpret medical test results or documents

Recognise when specimen collection is required

Relate results of the test to homœopathic symptomatology

Take into account opportunities to address waste minimisation, environmental responsibility and sustainable practice issues

Use homœopathic tools and resources

Use medical reference texts including homœopathic and western medicine texts

Use terminology correct to discipline

Use, monitor and maintain appropriate medical equipment

Evidence Required

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:

The individual being assessed must provide evidence of specified essential knowledge as well as skills

Observation of performance in the workplace or a simulated workplace (defined as a supervised clinic) is essential for assessment of this unit

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

Assessment of sole practitioners must include a range of clinical situations and different client groups covering at minimum, age, culture and gender

Assessment of sole practitioners must consider their unique workplace context, including:

interaction with others in the broader professional community as part of the sole practitioner's workplace

scope of practice as detailed in the qualification and component competency units

holistic/integrated assessment including:

working within the practice framework

performing a health assessment

assessing the client

planning treatment

providing treatment

Context of and specific resources for assessment:

An appropriately stocked and equipped clinic or simulated clinic environment

Reference texts

Local legal guidelines

Appropriate assessment environment

Skilled assessors

Method of assessment

Observation in the work place

Written assignments/projects or questioning should be used to assess knowledge

Case study and scenario as a basis for discussion of issues and strategies to contribute to best practice

Examples of assessment notes

Clinical skills involving direct client care are to be assessed initially in a simulated clinical setting (laboratory). If successful, a second assessment is to be conducted during workplace application under direct supervision

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 the following related competency units:

HLTCOM404C Communicate effectively with clients

HLTHIR301B Communicate and work effectively in health

HLTHOM601C Apply homœopathic diagnostic framework

HLTIN301C Comply with infection control policies and procedures


Range Statement

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.

Examination is organised means:

Consent is obtained from a parent/ guardian/ caregiver prior to commencing a physical examination of a minor or an adult under guardianship

Equipment is arranged

Equipment is checked/calibrated so that it is in good working order

Client and examiner are positioned

Examination is sequenced for efficiency and client and examiner comfort

Procedures are communicated may include:

Informing client of procedures to be carried out

Obtaining client consent at each stage of examination

An appropriate adult (parent/guardian/caregiver) must be present during examination of a minor or an adult under guardianship

Examination for vital signs must include competency in:

Measuring blood pressure, respiration and pulse rates, and temperature

Performing standardised sequence of examination

Using required equipment, including

sphygmomanometer

stethoscope

timing device

thermometer

peak flow meter and disposable mouth pieces, if required

Following standardised procedures for infection control

Areas of investigation may include:

Full screening examination

General appearance and vital signs

Skin

Head, eyes, ears, nose, oral cavity and throat

Neck

Breasts and axillae

Thorax and lungs

Heart and great vessels

Abdomen

Limbs

Neurological system

Lower back

Cardiovascular system

Reproductive system

Respiratory system

Gastrointestinal system

Urinary system

Endocrine system

Techniques include:

Inspection

Palpation

Auscultation

Percussion

Appropriate manoeuvres

Equipment must include:

Thermometer

Sphygmomanometer

Stethoscope

Timing device

Peak flow meter and disposable mouth pieces

Examination table

Otoscope

Penlight

Percussion (reflex) hammer

Measuring tape

Equipment for measuring height and weight

Goose-neck lamp or other light source

And may include:

Ophthalmoscope

Tuning fork(s)

Nasal speculum

Skin marking pencil

Glucometer and disposable lancets devices

Supplies required must include:

Half-sheet for draping

Examination gowns

Disposable gloves

Tongue depressors

Cotton-tipped swab

Gauze squares

Medi alcohol swabs

Hazard bags for infection control

Sharps containers

Instrument cleaning supplies

And may include:

Visual acuity charts

Goggles/protective eyewear

Extended interview may include:

Extended history taking

Formulating clinical diagnostic hypothesis

Data gathering and hypothesis testing

Identifying role of past medical history

Identifying role of client profile

Relating signs and symptoms to diagnostic areas using a standard system of clinical evaluation

Screening assessment must imply one of the following:

The need for further examination or investigation

The need for further evaluation of the signs and symptoms to establish a clinical diagnosis

A definite clinical diagnosis

A dangerous pathology or psychiatric condition

A condition which can be safely and satisfactorily managed by the practitioner

Screening assessment involves:

Establishing expected normal course of disease including:

natural duration of disease

progress, extension, radiation and pace

probability of remission

The need for referral may include:

Suspected dangerous pathology

Unknown symptom complex or condition

Signs of notifiable disease

Need for medical diagnostic information

Further diagnostic procedures may include:

Diagnostic laboratory tests

Diagnostic imaging

Referral to a diagnostician

Outcomes of referrals includes:

Ascertaining that diagnostic procedures or extended examination has been carried out by the appropriate practitioner

Assessing and analysing the data arising out of the referral


Sectors

Not Applicable


Employability Skills

This unit contains Employability Skills


Licensing Information

Not Applicable