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Evidence Guide: HLTAHW016 - Assess clients physical wellbeing

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

 

HLTAHW016 - Assess clients physical wellbeing

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

Elements define the essential outcomes.

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Initiate health assessment

  1. Seek to establish trust with the client, through active promotion of and strict adherence to confidentiality
  2. Obtain client’s history using effective, culturally appropriate and safe communication skills
  3. Seek additional health-related information from the client’s family and/or carer(s) and relevant community members with the client’s consent
  4. Consult relevant allied professionals and available documentation in relation to the health of the client
  5. Document all information about the client in accordance with organisational procedures and policies
Seek to establish trust with the client, through active promotion of and strict adherence to confidentiality

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Obtain client’s history using effective, culturally appropriate and safe communication skills

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Seek additional health-related information from the client’s family and/or carer(s) and relevant community members with the client’s consent

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Consult relevant allied professionals and available documentation in relation to the health of the client

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Document all information about the client in accordance with organisational procedures and policies

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Assess client’s physical health

  1. Explain the process and rationale of each examination and test to the client
  2. Perform physical and clinical assessments in line with organisational policies and procedures and with respect for community values, beliefs and gender roles
  3. Measure vital signs and identify significant variation from normal ranges and refer to senior staff member as required
  4. Use correct procedures and take precautions to collect and send specimens for pathology testing
  5. Accurately record all outcomes of assessments in accordance with organisational procedures and policies
  6. Identify non-clinical factors potentially responsible for significant variations from normal ranges and make repeat assessments
Explain the process and rationale of each examination and test to the client

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Perform physical and clinical assessments in line with organisational policies and procedures and with respect for community values, beliefs and gender roles

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Measure vital signs and identify significant variation from normal ranges and refer to senior staff member as required

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Use correct procedures and take precautions to collect and send specimens for pathology testing

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Accurately record all outcomes of assessments in accordance with organisational procedures and policies

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Identify non-clinical factors potentially responsible for significant variations from normal ranges and make repeat assessments

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Interpret and confirm health assessment findings

  1. Accurately identify a range of signs and symptoms of health conditions
  2. Recognise signs and symptoms of potentially serious underlying conditions and refer to senior health staff for advice
  3. Interpret the significance of health assessment findings in the context of the holistic health of the client
Accurately identify a range of signs and symptoms of health conditions

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Recognise signs and symptoms of potentially serious underlying conditions and refer to senior health staff for advice

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Interpret the significance of health assessment findings in the context of the holistic health of the client

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Identify any significant variations from normal range on the basis of health assessment data

  1. Consult other team members to confirm interpretations and clarify implications and significance of findings
  2. Seek assistance when findings are unclear or outside limits of own authority
  3. Report notifiable diseases identified to supervisor and/or an appropriate authority, in line with jurisdictional requirements
  4. Initiate action in relation to any issues requiring mandatory reporting according to procedural and legislative requirements
  5. Accurately document client history and examination findings in client’s file
Consult other team members to confirm interpretations and clarify implications and significance of findings

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Seek assistance when findings are unclear or outside limits of own authority

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

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

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Initiate action in relation to any issues requiring mandatory reporting according to procedural and legislative requirements

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Accurately document client history and examination findings in client’s file

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Summarise and present findings

  1. Provide client with information about findings of physical examination
  2. Check client understanding of information through appropriate questioning
  3. Provide client with information relevant to promoting and maintaining their health in a way they readily understand
  4. Support client to take a self-care approach to health in line with individual needs and organisational and community requirements
  5. Document and refer as necessary all discussions with client and/or significant others in client file according to organisational procedures and policies
Provide client with information about findings of physical examination

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Check client understanding of information through appropriate questioning

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Provide client with information relevant to promoting and maintaining their health in a way they readily understand

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Support client to take a self-care approach to health in line with individual needs and organisational and community requirements

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Document and refer as necessary all discussions with client and/or significant others in client file according to organisational procedures and policies

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Assess client’s physical health

  1. Explain the process and rationale of each examination and test to the client
  2. Perform physical and clinical assessments in line with organisational policies and procedures and with respect for community values, beliefs and gender roles
  3. Measure vital signs and identify significant variation from normal ranges and refer to senior staff member as required
  4. Use correct procedures and take precautions to collect and send specimens for pathology testing
  5. Accurately record all outcomes of assessments in accordance with organisational procedures and policies
  6. Identify non-clinical factors potentially responsible for significant variations from normal ranges and make repeat assessments
Explain the process and rationale of each examination and test to the client

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Perform physical and clinical assessments in line with organisational policies and procedures and with respect for community values, beliefs and gender roles

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Measure vital signs and identify significant variation from normal ranges and refer to senior staff member as required

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Use correct procedures and take precautions to collect and send specimens for pathology testing

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Accurately record all outcomes of assessments in accordance with organisational procedures and policies

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Identify non-clinical factors potentially responsible for significant variations from normal ranges and make repeat assessments

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. Initiate health assessment

1.1 Seek to establish trust with the client, through active promotion of and strict adherence to confidentiality

1.2 Obtain client’s history using effective, culturally appropriate and safe communication skills

1.3 Seek additional health-related information from the client’s family and/or carer(s) and relevant community members with the client’s consent

1.4 Consult relevant allied professionals and available documentation in relation to the health of the client

1.5 Document all information about the client in accordance with organisational procedures and policies

2. Assess client’s physical health

2.1 Explain the process and rationale of each examination and test to the client

2.2 Perform physical and clinical assessments in line with organisational policies and procedures and with respect for community values, beliefs and gender roles

2.3 Measure vital signs and identify significant variation from normal ranges and refer to senior staff member as required

2.4 Use correct procedures and take precautions to collect and send specimens for pathology testing

2.5 Accurately record all outcomes of assessments in accordance with organisational procedures and policies

2.6 Identify non-clinical factors potentially responsible for significant variations from normal ranges and make repeat assessments

3. Interpret and confirm health assessment findings

3.1 Accurately identify a range of signs and symptoms of health conditions

3.2 Recognise signs and symptoms of potentially serious underlying conditions and refer to senior health staff for advice

3.3 Interpret the significance of health assessment findings in the context of the holistic health of the client

3.4Identify any significant variations from normal range on the basis of health assessment data

3.5 Consult other team members to confirm interpretations and clarify implications and significance of findings

3.6 Seek assistance when findings are unclear or outside limits of own authority

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

3.8 Initiate action in relation to any issues requiring mandatory reporting according to procedural and legislative requirements

3.9 Accurately document client history and examination findings in client’s file

4. Summarise and present findings

4.1 Provide client with information about findings of physical examination

4.2 Check client understanding of information through appropriate questioning

4.3 Provide client with information relevant to promoting and maintaining their health in a way they readily understand

4.4 Support client to take a self-care approach to health in line with individual needs and organisational and community requirements

4.5 Document and refer as necessary all discussions with client and/or significant others in client file according to organisational procedures and policies

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. Initiate health assessment

1.1 Seek to establish trust with the client, through active promotion of and strict adherence to confidentiality

1.2 Obtain client’s history using effective, culturally appropriate and safe communication skills

1.3 Seek additional health-related information from the client’s family and/or carer(s) and relevant community members with the client’s consent

1.4 Consult relevant allied professionals and available documentation in relation to the health of the client

1.5 Document all information about the client in accordance with organisational procedures and policies

2. Assess client’s physical health

2.1 Explain the process and rationale of each examination and test to the client

2.2 Perform physical and clinical assessments in line with organisational policies and procedures and with respect for community values, beliefs and gender roles

2.3 Measure vital signs and identify significant variation from normal ranges and refer to senior staff member as required

2.4 Use correct procedures and take precautions to collect and send specimens for pathology testing

2.5 Accurately record all outcomes of assessments in accordance with organisational procedures and policies

2.6 Identify non-clinical factors potentially responsible for significant variations from normal ranges and make repeat assessments

3. Interpret and confirm health assessment findings

3.1 Accurately identify a range of signs and symptoms of health conditions

3.2 Recognise signs and symptoms of potentially serious underlying conditions and refer to senior health staff for advice

3.3 Interpret the significance of health assessment findings in the context of the holistic health of the client

3.4Identify any significant variations from normal range on the basis of health assessment data

3.5 Consult other team members to confirm interpretations and clarify implications and significance of findings

3.6 Seek assistance when findings are unclear or outside limits of own authority

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

3.8 Initiate action in relation to any issues requiring mandatory reporting according to procedural and legislative requirements

3.9 Accurately document client history and examination findings in client’s file

4. Summarise and present findings

4.1 Provide client with information about findings of physical examination

4.2 Check client understanding of information through appropriate questioning

4.3 Provide client with information relevant to promoting and maintaining their health in a way they readily understand

4.4 Support client to take a self-care approach to health in line with individual needs and organisational and community requirements

4.5 Document and refer as necessary all discussions with client and/or significant others in client file according to organisational procedures and policies

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:

assessed and monitored the physical wellbeing of at least five Aboriginal and/or Torres Strait Islander adults and children by:

- establishing a relationship of trust with clients and significant others

- taking a detailed history of the client

- explaining assessment methods and procedures to client and/or significant others

- observing and assessing client’s health, using appropriate tests and medical instrumentation

- recording observations

- questioning, assessing and monitoring client’s health status, issues and needs

- reviewing effectiveness of health care strategies and making appropriate revisions, taking prior history into consideration

- summarising and presenting findings in line with client needs and workplace requirements

- maintaining client records and upholding client confidentiality

- communicating with client’s family and/or significant others as required

- gaining informed consent to conduct assessment

- taking, considering and recording relevant details of client’s history (including body language)

- complying with and enforcing infection control guidelines

- using a structured approach to assessment

- interpreting common pathology tests

- taking full responsibility for assessment findings.

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, and follow-up of client

- mandatory reporting

- notifiable communicable diseases

- limits of own ability and authority

- reporting procedures

- documentation

key elements of comprehensive and accurate physical, social/emotional and mental health assessment

anatomy/physiology and associated microbiology, pathophysiology (disease processes) and pharmacology including:

- respiratory system

- circulatory system

- integumentary system

- digestive system

- genitourinary system

- endocrine system

- musculoskeletal system

- nervous system

- reproductive systems

pathophysiology associated with these systems, including:

- acute chronic condition and conditions associated with a specific body system

- injuries

- wounds

- arthritis

- inflammation

- impact of alcohol and drugs

pharmacology to address pathophysiology, including:

- medications and forms of administration

- antibiotics

- analgesics

- contraindications

- complications

- psychiatric medications

- oral hypoglycaemics

- insulin

procedures for health tests and ‘normal’ range of test outcomes, including:

- blood pressure (for adults and children)

- temperature

- pulse rate

- respiratory and peak flow rates

- height and weight

- components of urine

- near vision and pinhole visual acuity testing

visual examination of eye and ear

blood glucose (sugar) and haemoglobin levels

in relation to cardiovascular diseases:

- the concept of ‘cardiovascular risk factors’, the significance of an individual having multiple risk factors and the concept of ‘high absolute risk’

- the importance of reduction of saturated fats and sugar-sweetened soft drinks, increased physical activity and smoking cessation in reducing the risk of heart and kidney disease in Aboriginal and/or Torres Strait Islander populations

in relation to diabetes mellitus:

- basic pathophysiology of type II contrasted with type I diabetes mellitus

- complications of diabetes (including heart disease and stroke; renal failure; retinal damage and blindness; nerve damage and infection resulting in amputation; impotence)

- the main elements of the ‘diabetes check up’

- the procedure for taking retinal photographs

- basic anatomical features and abnormalities on a retinal photograph

- the content of client education for diabetes covering diet, physical activity, foot-care, and use of diabetes medicines

in relation to chronic renal disease:

- basic pathophysiology of chronic renal failure (causes, body systems affected, natural history)

- factors which may worsen or accelerate renal failure (including: high blood pressure, anti-inflammatory drugs, poor diabetes control, dehydration, high protein diet)

- clinical features of advanced renal failure

- the importance of early detection of renal disease in efforts to defer or prevent end-stage renal failure

- options for treatment of end-stage renal failure (haemodialysis, chronic ambulatory peritoneal dialysis, transplant).

familiarity with a range of other common chronic conditions in Aboriginal and/or Torres Strait Islander populations:

- chronic liver disease – causes, clinical features and principles of management (including hepatitis B, hepatitis C, alcoholic liver disease and cirrhosis)

- chronic obstructive lung disease, relationship to smoking and principles of management

basic nature, management and associated risk factors for common diseases

commonly (including complete blood tests and urine analysis) and specifically requested pathology tests and the correct methods of collection, storage and transport of specimens

the clinical significance of abnormal findings on pathology tests with particular reference to use of medicines

knowledge of care planning and self-management support tools

relevant criteria for evaluation of effectiveness of care plan

features of chronic illness, including:

- complex causality

- multiple risk factors

- long latency periods

- a prolonged course of illness

- functional impairment or disability

specific chronic conditions affecting Aboriginal and/or Torres Strait Islander clients and communities, including:

- cardiovascular disease

- diabetes

- cancer

- chronic respiratory disease

- chronic kidney disease

- asthma

- arthritis

- oral disease

determinants of chronic conditions, including:

- smoking

- physical activity

- nutrition

- alcohol intake

- use of illicit drugs

- obesity, weight and waist circumference

- unsafe sexual practices

- genetic factors

linkages between conditions such as diabetes and eye health, nutrition and hearing, etc.