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Evidence Guide: HLTAMBCR401C - 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

 

HLTAMBCR401C - Deliver basic clinical care

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

Make initial client assessment

  1. Conduct pre-planning before arrival at scene based on information communicated in request for service
  2. Conduct scene survey according to local ambulance standard operation procedure
  3. Conduct primary survey according to local ambulance standard operation procedure
  4. Check and monitor vital signs in accordance with local ambulance standard operation procedure
  5. Obtain history of the event
  6. Conduct secondary survey, incorporating a systematic physical examination of the whole body
  7. Identify chief complaints, including pattern and mechanism of illness or injury as a basis for prioritising treatment
  8. Obtain client's medical history to ensure appropriate treatment is selected
  9. Determine client's potential or actual time criticality versus transport criticality
  10. Assess transport requirements and appropriate destination, considering client's condition and the type of resources needed to ensure that requirements of urgency and client care are met
Conduct pre-planning before arrival at scene based on information communicated in request for service

Completed
Date:

Teacher:
Evidence:

 

 

 

 

 

 

 

Conduct scene survey according to local ambulance standard operation procedure

Completed
Date:

Teacher:
Evidence:

 

 

 

 

 

 

 

Conduct primary survey according to local ambulance standard operation procedure

Completed
Date:

Teacher:
Evidence:

 

 

 

 

 

 

 

Check and monitor vital signs in accordance with local ambulance standard operation procedure

Completed
Date:

Teacher:
Evidence:

 

 

 

 

 

 

 

Obtain history of the event

Completed
Date:

Teacher:
Evidence:

 

 

 

 

 

 

 

Conduct secondary survey, incorporating a systematic physical examination of the whole body

Completed
Date:

Teacher:
Evidence:

 

 

 

 

 

 

 

Identify chief complaints, including pattern and mechanism of illness or injury as a basis for prioritising treatment

Completed
Date:

Teacher:
Evidence:

 

 

 

 

 

 

 

Obtain client's medical history to ensure appropriate treatment is selected

Completed
Date:

Teacher:
Evidence:

 

 

 

 

 

 

 

Determine client's potential or actual time criticality versus transport criticality

Completed
Date:

Teacher:
Evidence:

 

 

 

 

 

 

 

Assess transport requirements and appropriate destination, considering client's condition and the type of resources needed to ensure that requirements of urgency and client care are met

Completed
Date:

Teacher:
Evidence:

 

 

 

 

 

 

 

Plan basic out-of-hospital client care

  1. Establish priorities of care based on initial client assessment according to local ambulance standard operation procedure
  2. Develop contingency plans based on mechanisms of injury and potential for client deterioration according to local ambulance standard operation procedure
Establish priorities of care based on initial client assessment according to local ambulance standard operation procedure

Completed
Date:

Teacher:
Evidence:

 

 

 

 

 

 

 

Develop contingency plans based on mechanisms of injury and potential for client deterioration according to local ambulance standard operation procedure

Completed
Date:

Teacher:
Evidence:

 

 

 

 

 

 

 

Implement basic client care procedures

  1. Commence all client care procedures and drug therapies within the individual's level of expertise and authority to practise and limits of the local ambulance clinical practice guidelines/protocols
  2. Where the situation or client's condition requires treatment that is outside the scope or authority to practise of the attending officer, immediately recognise the need for assistance and seek help
  3. Correctly operate ambulance equipment as required for client management according to manufacturer/supplier's instructions and local clinical guidelines/protocols
  4. Implement client care techniques in accordance with infection control procedures and techniques
  5. Use safe lifting and client handling techniques in accordance with WHS requirements and organisation policy and procedures
Commence all client care procedures and drug therapies within the individual's level of expertise and authority to practise and limits of the local ambulance clinical practice guidelines/protocols

Completed
Date:

Teacher:
Evidence:

 

 

 

 

 

 

 

Where the situation or client's condition requires treatment that is outside the scope or authority to practise of the attending officer, immediately recognise the need for assistance and seek help

Completed
Date:

Teacher:
Evidence:

 

 

 

 

 

 

 

Correctly operate ambulance equipment as required for client management according to manufacturer/supplier's instructions and local clinical guidelines/protocols

Completed
Date:

Teacher:
Evidence:

 

 

 

 

 

 

 

Implement client care techniques in accordance with infection control procedures and techniques

Completed
Date:

Teacher:
Evidence:

 

 

 

 

 

 

 

Use safe lifting and client handling techniques in accordance with WHS requirements and organisation policy and procedures

Completed
Date:

Teacher:
Evidence:

 

 

 

 

 

 

 

Monitor basic client care and modify as required

  1. Re-assess client and presenting conditions at appropriate intervals and modify treatment as required according to local ambulance standard operation procedure
  2. Modify drug therapy noting effectiveness of treatment regime and amend according to client's condition
  3. Identify and initiate need for advanced levels of intervention and action
Re-assess client and presenting conditions at appropriate intervals and modify treatment as required according to local ambulance standard operation procedure

Completed
Date:

Teacher:
Evidence:

 

 

 

 

 

 

 

Modify drug therapy noting effectiveness of treatment regime and amend according to client's condition

Completed
Date:

Teacher:
Evidence:

 

 

 

 

 

 

 

Identify and initiate need for advanced levels of intervention and action

Completed
Date:

Teacher:
Evidence:

 

 

 

 

 

 

 

Hand over client requiring basic care

  1. Document relevant client details according to local ambulance standard operation procedure
  2. Maintain client confidentiality at all times
  3. Ensure documentation for handover procedures conveys all necessary information
  4. Convey information appropriately to those individuals involved in ongoing client care to facilitate understanding and optimise continuing care
  5. Maintain client care until responsibility for client care is taken over by staff of the receiving agency
Document relevant client details according to local ambulance standard operation procedure

Completed
Date:

Teacher:
Evidence:

 

 

 

 

 

 

 

Maintain client confidentiality at all times

Completed
Date:

Teacher:
Evidence:

 

 

 

 

 

 

 

Ensure documentation for handover procedures conveys all necessary information

Completed
Date:

Teacher:
Evidence:

 

 

 

 

 

 

 

Convey information appropriately to those individuals involved in ongoing client care to facilitate understanding and optimise continuing care

Completed
Date:

Teacher:
Evidence:

 

 

 

 

 

 

 

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

Completed
Date:

Teacher:
Evidence:

 

 

 

 

 

 

 

Assessed

Teacher: ___________________________________ Date: _________

Signature: ________________________________________________

Comments:

 

 

 

 

 

 

 

 

Instructions to Assessors

Evidence Guide

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 establish acquisition of Essential Knowledge across the Range Statement outlined in HLTAP401A Confirm physical health status prior to assessment of skills application for this unit

Skills involving direct client care are to be assessed initially in a simulated clinical setting (laboratory/practical)

After successful completion of initial assessment, a second assessment is to be conducted during workplace application under direct supervision

The application of skills and knowledge described in this competency unit should be assessed in conjunction with the application of knowledge and skills identified in HLTAP401A Confirm physical health status

Candidates must demonstrate their ability to apply essential knowledge and skills identified for this competency unit before undertaking independent workplace application

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

Resource implications:

Access to appropriate workplace and simulation of realistic workplace setting where assessment can be conducted

Evidence must include observation of performance in the workplace and a simulated work situation

Access to equipment and resources normally used in the workplace

Method of assessment:

Evidence must include observation of performance in an actual or simulated work setting

Observations, questioning and evidence gathered from the workplace environment

Demonstration over a period of time to ensure consistency of performance

Required Skills and Knowledge

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:

Basic physiology and anatomy as defined in unit HLTAP401A Confirm physical health status

Procedures and equipment used for Basic (or Advanced) Life Support, as specified within authorised limits defined by legal requirements and organisation policies

Receiving facility requirements or how to access these requirements

Clinical Practice Guidelines/Protocols and ambulance equipment

Organisation policies for basic client care

Understanding of client psychology

Significance of assessment findings

Organisation administrative policies and procedures

Function of documentation being provided

Essential skills:

It is critical that the candidate demonstrate the ability to:

Apply the clinical problem solving process as it applies to basic client care

Apply knowledge to recognise the patterns of illness and injury relevant to the delivery of basic client care

Apply knowledge and understanding in both familiar and unfamiliar situations

Correctly use approved documents

Correctly document client and incident details

Interact with receiving facility personnel

Conduct initial client assessment to detect and correct any immediate life threatening conditions, including primary survey of:

danger

response

airway

breathing

circulation

Accurately complete all documentation and supply all relevant client information to receiving facility staff under a variety of conditions and circumstances

Implement basic clinical procedures

Collect and document relevant information

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:

Use oral communication skills (language competence) required to fulfil job roles as specified by the organisation, including:

asking questions

active listening

asking for clarification from client or other persons at the scene

negotiating solutions

acknowledging and responding to a range of views.

Use written communication skills (literacy competence) required to fulfil job roles as specified by organisation, including:

reading and understanding incident reports, case management materials and manufacturers' specifications for the use of materials and equipment,

preparing handover reports for receiving agency staff

Use interpersonal skills, including:

working with others

showing empathy with client and relatives

relating to persons from differing cultural, social and religious backgrounds.

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.

Pre-planning may include, but is not limited to:

Potential resources required such as equipment, personnel, other services

Access and egress requirements

Identification of potential safety issues

Scene survey may include, but is not limited to:

Identification of dangers and hazards

Operational safety

Confirmation of location and initial case details

Determination of access, egress and initial equipment requirements

Client assessment must include but is not limited to:

Integration of principles of anatomy and physiology, primary, vital sign and secondary surveys, including non-obvious clinical signs, using applied clinical knowledge at the basic level of client care

Primary survey must include, but is not limited to:

Dangers

Response

Airway

Breathing

Circulation

Vital signs may include, but are not limited to:

Conscious state assessment e.g. Glasgow Coma Score, AVPU alert, voice, pain, unconscious

Respiratory status assessment, e.g. rate, rhythm, effort and breath sounds

Perfusion status assessment, e.g. pulse, blood pressure, capillary refill and skin

Secondary survey may include, but is not limited to:

Systematic head to toe physical body examination

Assessment of time criticality as indicated by physiological status or pattern and mechanism of injury

History of event includes present history and may be elicited from:

Client

Bystanders

Primary carers

Medical personnel

Medi-alert bracelet

Evidence at the scene

Client history includes:

Pre-existing conditions

Allergies

Current medication or treatment

Chief complaints, including pattern and mechanism of illness or injury must include, but are not limited to:

Kinematics of trauma

Burns trauma

Extremity trauma

Neurological insult

Mental health disorders

Metabolic disorders

Poisoning or overdose emergency

Cardio-vascular insult

Hypoperfusion

Immunological disorders

Respiratory disorders

Thoracic trauma

Abdominal disorders or trauma

Urogenital disorders or trauma

Gynaecological disorders

Medical or traumatic obstetric disorders

Paediatric medical or traumatic disorders

Medical or traumatic geriatric disorders

Situation involves a client in need and may include, but is not limited to:

Transfer of client with pre-diagnosed illness or injury

Transfer of client with sudden undiagnosed illness or injury

Management of client in trauma or with undiagnosed illness

Mode of transport is selected for its availability and potential to provide the means of mobile care most suited to the needs of the client and may include, but is not limited to:

Road ambulances

Clinic cars

Rescue or retrieval units

Fixed and rotary wing aircraft

Water-borne craft

Four wheel drive vehicle

Client management will need to take into account:

Location and nature of incident

Environmental conditions

Number of casualties and potential casualties

Use and availability of ambulance equipment and pharmaceuticals

Drug therapy used in the treatment of a client's condition may include, but is not limited to:

Basic pharmacological agents for management of bronchospasm, pain (medical including cardiac) trauma and hypoglycaemia

Other medications as indicated by local ambulance clinical guidelines/protocols

Interventions expected to be utilised where client's condition indicates they would be of some benefit include but are not limited to:

Airway management ie manual airway techniques, oropharyngeal airway and suction

Automated External Defibrillation (AED)

Intramuscular injections

Traction and other types of splinting

Non-verbal cues may include, but are not limited to:

Posturing

Gait

Anxiety

Types of documentation may include, but are not limited to:

Incident reports

Handover reports

Case management material

Persons authorised to receive confidential information may include, but are not limited to:

Medical personnel at hospitals and surgeries

Police Officers

Legal practitioners

Others, where approved as acting in the best interests of the client

Reports may include, but are not limited to:

Oral or written reports

Client handover

Incident reports

Patient Care Record

Case management material

Acts and regulations are those specified in each State/Territory and include, but are not limited to:

Confidentiality and privacy

Freedom of information

Drug and poisons regulations

Health

Mental Health

Policy and procedures may include, but are not limited to:

Organisation policies and procedures

Documentation

Reporting of client medical information

Occupational Health and safety

Clinical Practice Guidelines/Protocols

Operational

Medico-legal