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Evidence Guide: HLTAMB007 - Assess and deliver basic clinical care

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

 

HLTAMB007 - Assess and deliver basic clinical care

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

Elements define the essential outcomes

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Make initial incident and patient assessment

  1. Conduct pre-planning before arrival at scene based on information communicated in the request for service
  2. Conduct scene survey according to established clinical guidelines and protocols
  3. Conduct primary survey of patient including taking vital signs
  4. Conduct a secondary survey, including a systematic physical examination of the whole body using applied clinical knowledge
  5. Obtain and document history of the event
  6. Identify patient’s main complaints as a basis for systematic prioritised treatment
  7. Apply situational knowledge of the patient to guide selection of appropriate treatment options
  8. Determine the time-critical issues given resource considerations
  9. Assess transport requirements and appropriate destination, versus transport criticality, to ensure requirements of urgency and patient care are met
Conduct pre-planning before arrival at scene based on information communicated in the request for service

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Conduct scene survey according to established clinical guidelines and protocols

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Conduct primary survey of patient including taking vital signs

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Conduct a secondary survey, including a systematic physical examination of the whole body using applied clinical knowledge

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Obtain and document history of the event

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Identify patient’s main complaints as a basis for systematic prioritised treatment

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Apply situational knowledge of the patient to guide selection of appropriate treatment options

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Determine the time-critical issues given resource considerations

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Assess transport requirements and appropriate destination, versus transport criticality, to ensure requirements of urgency and patient care are met

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Plan basic pre-hospital/out-of-hospital patient care

  1. Establish priorities of care based on initial patient assessment according to established clinical guidelines and protocols
  2. Develop a treatment plan and outline treatment priorities
  3. Identify and develop contingency plans based on mechanisms of injury and potential for patient deterioration according to established clinical guidelines and protocols
Establish priorities of care based on initial patient assessment according to established clinical guidelines and protocols

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Develop a treatment plan and outline treatment priorities

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Identify and develop contingency plans based on mechanisms of injury and potential for patient deterioration according to established clinical guidelines and protocols

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Implement basic patient care procedures

  1. Implement all patient care procedures and pharmacological therapies within own level of expertise and authority to practise, and the limits of clinical guidelines and protocols
  2. Identify the need to seek assistance immediately where the situation or patient’s condition requires treatment that is outside scope or authority to practise
  3. Operate equipment as required for patient management according to manufacturer or supplier’s instructions and clinical guidelines and protocols
  4. Apply infection prevention and control principles to patient care
  5. Use safe lifting and patient handling techniques in accordance with workplace health and safety (WHS) requirements and organisation policy and procedures
Implement all patient care procedures and pharmacological therapies within own level of expertise and authority to practise, and the limits of clinical guidelines and protocols

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Identify the need to seek assistance immediately where the situation or patient’s condition requires treatment that is outside scope or authority to practise

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Operate equipment as required for patient management according to manufacturer or supplier’s instructions and clinical guidelines and protocols

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Apply infection prevention and control principles to patient care

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Use safe lifting and patient handling techniques in accordance with workplace health and safety (WHS) requirements and organisation policy and procedures

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Monitor basic patient care and modify as required

  1. Re-assess patient at appropriate intervals and modify treatment as required according to established clinical guidelines and protocols
  2. Monitor pharmacological outcomes, noting effectiveness of treatment regime and amend according to patient’s condition
Re-assess patient at appropriate intervals and modify treatment as required according to established clinical guidelines and protocols

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Monitor pharmacological outcomes, noting effectiveness of treatment regime and amend according to patient’s condition

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Handover patient to a healthcare facility

  1. Document relevant patient details according to established clinical guidelines and protocols
  2. Maintain patient confidentiality at all times
  3. Ensure documentation for clinical handover procedures contains all necessary information
  4. Convey information appropriately to authorised individuals involved in ongoing patient care
  5. Maintain patient care until responsibility for patient is taken over by staff of the receiving agency
Document relevant patient details according to established clinical guidelines and protocols

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Maintain patient confidentiality at all times

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Ensure documentation for clinical handover procedures contains all necessary information

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Convey information appropriately to authorised individuals involved in ongoing patient care

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Maintain patient care until responsibility for patient is taken over by staff of the receiving agency

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Assessed

Teacher: ___________________________________ Date: _________

Signature: ________________________________________________

Comments:

 

 

 

 

 

 

 

 

Instructions to Assessors

Evidence Guide

ELEMENT

PERFORMANCE CRITERIA

Elements define the essential outcomes

Performance criteria describe the performance needed to demonstrate achievement of the element.

1. Make initial incident and patient assessment

1.1 Conduct pre-planning before arrival at scene based on information communicated in the request for service

1.2 Conduct scene survey according to established clinical guidelines and protocols

1.3 Conduct primary survey of patient including taking vital signs

1.4 Conduct a secondary survey, including a systematic physical examination of the whole body using applied clinical knowledge

1.5 Obtain and document history of the event

1.6 Identify patient’s main complaints as a basis for systematic prioritised treatment

1.7 Apply situational knowledge of the patient to guide selection of appropriate treatment options

1.8 Determine the time-critical issues given resource considerations

1.9 Assess transport requirements and appropriate destination, versus transport criticality, to ensure requirements of urgency and patient care are met

2. Plan basic pre-hospital/out-of-hospital patient care

2.1 Establish priorities of care based on initial patient assessment according to established clinical guidelines and protocols

2.2 Develop a treatment plan and outline treatment priorities

2.3 Identify and develop contingency plans based on mechanisms of injury and potential for patient deterioration according to established clinical guidelines and protocols

3. Implement basic patient care procedures

3.1 Implement all patient care procedures and pharmacological therapies within own level of expertise and authority to practise, and the limits of clinical guidelines and protocols

3.2 Identify the need to seek assistance immediately where the situation or patient’s condition requires treatment that is outside scope or authority to practise

3.3 Operate equipment as required for patient management according to manufacturer or supplier’s instructions and clinical guidelines and protocols

3.4 Apply infection prevention and control principles to patient care

3.5 Use safe lifting and patient handling techniques in accordance with workplace health and safety (WHS) requirements and organisation policy and procedures

4. Monitor basic patient care and modify as required

4.1 Re-assess patient at appropriate intervals and modify treatment as required according to established clinical guidelines and protocols

4.2 Monitor pharmacological outcomes, noting effectiveness of treatment regime and amend according to patient’s condition

5. Handover patient to a healthcare facility

5.1 Document relevant patient details according to established clinical guidelines and protocols

5.2 Maintain patient confidentiality at all times

5.3 Ensure documentation for clinical handover procedures contains all necessary information

5.4 Convey information appropriately to authorised individuals involved in ongoing patient care

5.5 Maintain patient care until responsibility for patient is taken over by staff of the receiving agency

Required Skills and Knowledge

ELEMENT

PERFORMANCE CRITERIA

Elements define the essential outcomes

Performance criteria describe the performance needed to demonstrate achievement of the element.

1. Make initial incident and patient assessment

1.1 Conduct pre-planning before arrival at scene based on information communicated in the request for service

1.2 Conduct scene survey according to established clinical guidelines and protocols

1.3 Conduct primary survey of patient including taking vital signs

1.4 Conduct a secondary survey, including a systematic physical examination of the whole body using applied clinical knowledge

1.5 Obtain and document history of the event

1.6 Identify patient’s main complaints as a basis for systematic prioritised treatment

1.7 Apply situational knowledge of the patient to guide selection of appropriate treatment options

1.8 Determine the time-critical issues given resource considerations

1.9 Assess transport requirements and appropriate destination, versus transport criticality, to ensure requirements of urgency and patient care are met

2. Plan basic pre-hospital/out-of-hospital patient care

2.1 Establish priorities of care based on initial patient assessment according to established clinical guidelines and protocols

2.2 Develop a treatment plan and outline treatment priorities

2.3 Identify and develop contingency plans based on mechanisms of injury and potential for patient deterioration according to established clinical guidelines and protocols

3. Implement basic patient care procedures

3.1 Implement all patient care procedures and pharmacological therapies within own level of expertise and authority to practise, and the limits of clinical guidelines and protocols

3.2 Identify the need to seek assistance immediately where the situation or patient’s condition requires treatment that is outside scope or authority to practise

3.3 Operate equipment as required for patient management according to manufacturer or supplier’s instructions and clinical guidelines and protocols

3.4 Apply infection prevention and control principles to patient care

3.5 Use safe lifting and patient handling techniques in accordance with workplace health and safety (WHS) requirements and organisation policy and procedures

4. Monitor basic patient care and modify as required

4.1 Re-assess patient at appropriate intervals and modify treatment as required according to established clinical guidelines and protocols

4.2 Monitor pharmacological outcomes, noting effectiveness of treatment regime and amend according to patient’s condition

5. Handover patient to a healthcare facility

5.1 Document relevant patient details according to established clinical guidelines and protocols

5.2 Maintain patient confidentiality at all times

5.3 Ensure documentation for clinical handover procedures contains all necessary information

5.4 Convey information appropriately to authorised individuals involved in ongoing patient care

5.5 Maintain patient care until responsibility for patient is taken over by staff of the receiving agency

The candidate must show evidence of the ability to complete tasks outlined in elements and performance criteria of this unit, manage task and manage contingencies in the context of the job role. There must be evidence that the candidate has:

• performed the activities outlined in the performance criteria of this unit during a period of at least 80 hours under clinical supervision in the workplace

• performed a clinical assessment and implemented basic care in an pre-hospital/out-of-hospital context on 3 different patients for an illness or trauma impacting health status including:

− performing primary survey

− performing secondary survey – systematic head to toe physical body examination including vital signs and level of consciousness

− planning and implementing basic clinical care based on assessment and time-criticality

− monitoring patient

− safely delivering patient to receiving facility or service

• performed basic life support on an adult, child and infant simulation manikin according to established clinical guidelines and protocols.

The candidate must be able to demonstrate essential knowledge required to effectively complete tasks outlined in elements and performance criteria of this unit, manage tasks and manage contingencies in the context of the work role. This includes knowledge of:

• assessment and interpretation of vital signs including:

- level of consciousness, covering for example

o Glasgow Coma Score (GCS)

o alert, voice, pain, unconscious (AVPU)

- respiratory status assessment – for example, rate, rhythm, effort and breath sounds

- temperature status – for example, febrile or afebrile or hypothermic

- blood volume and perfusion status assessment– for example pulse, blood pressure, capillary refill and skin

• basic anatomy and physiology in recognising body systems:

- cardiovascular

- respiratory

- musculo-skeletal

- endocrine

- nervous

- digestive

- urinary

- reproductive

- integumentary

- lymphatic

- special senses

• basic life support, including procedures and equipment used as specified within established clinical guidelines and protocols

• chief complaints when attending pre-hospital/out-of-hospital situations including trauma and medical disorders and possible actions to alleviate complaints

• clinical practice guidelines and protocols

• how to accurately obtain and document patient medical history including pre-existing conditions, allergies, social and emotional wellbeing, and current medication or treatment plans to provide to receiving health facility workers

• national and State/Territory legal and ethical considerations for emergency health care workers relevant to pre-hospital/out-of-hospital care, and how these are applied in organisations including:

- children in the workplace

- continuing professional education

- discrimination

- duty of care

- human rights

- informed consent

- mandatory reporting

- practitioner/client boundaries

- privacy, confidentiality and disclosure

- specific Commonwealth legislation and State/Territory legislation or regulation for health care workers including, for example:

o children and young people

o anti-discrimination

o disability

o health, drugs and poisons

o mental health

o health records and information privacy

o industrial relations

- National Safety and Quality Health Service (NSQHS) Standards

- industrial regulations

- work role boundaries – responsibilities and limitations

- work health and safety

• organisational administrative and patient care policies and procedures

• primary survey and secondary survey

• receiving facility requirements or how to access these requirements

• recognise the patterns of illness and injury relevant to the delivery of basic clinical patient care

• situations where the required patient treatment is outside the scope or authority to practice of the attending worker.