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Evidence Guide: HLTAHW007 - Undertake basic health assessments

Student: __________________________________________________

Signature: _________________________________________________

Tips for gathering evidence to demonstrate your skills

The important thing to remember when gathering evidence is that the more evidence the better - that is, the more evidence you gather to demonstrate your skills, the more confident an assessor can be that you have learned the skills not just at one point in time, but are continuing to apply and develop those skills (as opposed to just learning for the test!). Furthermore, one piece of evidence that you collect will not usualy demonstrate all the required criteria for a unit of competency, whereas multiple overlapping pieces of evidence will usually do the trick!

From the Wiki University

 

HLTAHW007 - Undertake basic health assessments

What evidence can you provide to prove your understanding of each of the following citeria?

Elements define the essential outcomes.

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Obtain client information

  1. Establish a relationship of trust with the client by demonstrating and respecting confidentiality
  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
  3. Access available documentation and written sources of information in relation to client’s health
  4. Consult relevant allied health professionals about client’s health
  5. Accurately record client information on client file according to organisation procedures and policies
Establish a relationship of trust with the client by demonstrating and respecting confidentiality

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

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

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Access available documentation and written sources of information in relation to client’s health

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Consult relevant allied health professionals about client’s health

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Accurately record client information on client file according to organisation procedures and policies

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Perform basic physical examination

  1. Explain the purpose and procedures involved in the examination to the client using culturally appropriate and safe communication skills
  2. Confirm client understanding and gain client consent to the examination
  3. Consider and respect Aboriginal and/or Torres Strait Islander community values, beliefs and gender roles when undertaking examination
  4. Conduct examination according to organisation procedures and policies, standard infection control and workplace health and safety requirements
  5. Accurately record measurements and findings and identify any significant variation from normal ranges according to organisational procedures
  6. Identify non-clinical factors potentially responsible for significant variations identified and repeat assessments as required
  7. Use, maintain and regularly clean medical equipment according to organisational procedures, standard infection control and workplace health and safety requirements
Explain the purpose and procedures involved in the examination to the client using culturally appropriate and safe communication skills

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Confirm client understanding and gain client consent to the examination

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Consider and respect Aboriginal and/or Torres Strait Islander community values, beliefs and gender roles when undertaking examination

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Conduct examination according to organisation procedures and policies, standard infection control and workplace health and safety requirements

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Accurately record measurements and findings and identify any significant variation from normal ranges according to organisational procedures

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Identify non-clinical factors potentially responsible for significant variations identified and repeat assessments as required

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Use, maintain and regularly clean medical equipment according to organisational procedures, standard infection control and workplace health and safety requirements

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Summarise and present findings

  1. Accurately document client history and examination findings in the client’s file in accordance with organisational policies and procedures
  2. Present and discuss client history and findings of physical examination with primary health care team according to organisational policies and procedures
  3. Identify common, uncomplicated health conditions based on history, physical examination and available information about presenting problem
  4. Recognise and assess self-management issues for clients with chronic conditions with primary health care team
  5. Promptly inform senior health staff about serious or potentially serious health problems including chronic conditions, according to organisational procedures and policies
  6. Identify and confirm with supervisor issues arising out of examination requiring mandatory notification
  7. Report notifiable diseases identified to supervisor and/or an appropriate authority in line with jurisdictional requirements
Accurately document client history and examination findings in the client’s file in accordance with organisational policies and procedures

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Present and discuss client history and findings of physical examination with primary health care team according to organisational policies and procedures

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Identify common, uncomplicated health conditions based on history, physical examination and available information about presenting problem

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Recognise and assess self-management issues for clients with chronic conditions with primary health care team

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Promptly inform senior health staff about serious or potentially serious health problems including chronic conditions, according to organisational procedures and policies

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Identify and confirm with supervisor issues arising out of examination requiring mandatory notification

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Report notifiable diseases identified to supervisor and/or an appropriate authority in line with jurisdictional requirements

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Support client’s physical wellbeing

  1. Explain findings of physical examination to client in a culturally appropriate and safe manner according to organisation policies and procedures
  2. Support client to improve and maintain health through a self-care approach and provide brief intervention as required
  3. Discuss with the client and/or significant others any identified barriers and options to self care for clients with chronic conditions
  4. Check for client understanding of information and encourage client to ask questions about health care
Explain findings of physical examination to client in a culturally appropriate and safe manner according to organisation policies and procedures

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Support client to improve and maintain health through a self-care approach and provide brief intervention as required

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Discuss with the client and/or significant others any identified barriers and options to self care for clients with chronic conditions

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Check for client understanding of information and encourage client to ask questions about health care

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Support client’s physical wellbeing

  1. Explain findings of physical examination to client in a culturally appropriate and safe manner according to organisation policies and procedures
  2. Support client to improve and maintain health through a self-care approach and provide brief intervention as required
  3. Discuss with the client and/or significant others any identified barriers and options to self care for clients with chronic conditions
  4. Check for client understanding of information and encourage client to ask questions about health care
Explain findings of physical examination to client in a culturally appropriate and safe manner according to organisation policies and procedures

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Support client to improve and maintain health through a self-care approach and provide brief intervention as required

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Discuss with the client and/or significant others any identified barriers and options to self care for clients with chronic conditions

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Check for client understanding of information and encourage client to ask questions about health care

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Assessed

Teacher: ___________________________________ Date: _________

Signature: ________________________________________________

Comments:

 

 

 

 

 

 

 

 

Instructions to Assessors

Evidence Guide

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

Required Skills and Knowledge

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

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.

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.