NTISthis.com

Evidence Guide: HLTDEF003 - Perform the duties of a scribe during casualty resuscitation

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

 

HLTDEF003 - Perform the duties of a scribe during casualty resuscitation

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

Elements define the essential outcomes

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Prepare for the role of scribe

  1. Prepare resuscitation documentation prior to arrival of casualty
  2. Prepare resuscitation area to receive the casualtyin accordance with preliminary clinical data obtained and direction from resuscitation team leader
  3. Prepare own personal protective equipment in accordance with organisation policies and procedures
  4. Follow guidance from team leader and resuscitation team members in accordance with prescribed role
Prepare resuscitation documentation prior to arrival of casualty

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Prepare resuscitation area to receive the casualtyin accordance with preliminary clinical data obtained and direction from resuscitation team leader

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Prepare own personal protective equipment in accordance with organisation policies and procedures

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Follow guidance from team leader and resuscitation team members in accordance with prescribed role

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Participate as a scribe in the resuscitation

  1. Follow personal hygiene and infection control procedures
  2. Ascertain casualty identity and history and record accurately
  3. Record treatment information and casualty’s response to treatment
  4. Maintain chronological record of events and procedures of the resuscitation
  5. Communicate relevant treatment information to other team members to aid in the continuity of care of the casualty
Follow personal hygiene and infection control procedures

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Ascertain casualty identity and history and record accurately

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Record treatment information and casualty’s response to treatment

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Maintain chronological record of events and procedures of the resuscitation

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Communicate relevant treatment information to other team members to aid in the continuity of care of the casualty

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Perform post resuscitation duties

  1. Accurately complete all relevant documentation
  2. Provide documentation to team leader for authorisation
  3. Organise ongoing casualty transfer in accordance with procedures
  4. Refurbish resuscitation area in preparation for the next resuscitation
  5. Participate in post event team debrief as applicable
Accurately complete all relevant documentation

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Provide documentation to team leader for authorisation

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Organise ongoing casualty transfer in accordance with procedures

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Refurbish resuscitation area in preparation for the next resuscitation

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Participate in post event team debrief as applicable

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. Prepare for the role of scribe

1.1 Prepare resuscitation documentation prior to arrival of casualty

1.2 Prepare resuscitation area to receive the casualtyin accordance with preliminary clinical data obtained and direction from resuscitation team leader

1.3 Prepare own personal protective equipment in accordance with organisation policies and procedures

1.4 Follow guidance from team leader and resuscitation team members in accordance with prescribed role

2. Participate as a scribe in the resuscitation

2.1 Follow personal hygiene and infection control procedures

2.2 Ascertain casualty identity and history and record accurately

2.3 Record treatment information and casualty’s response to treatment

2.4 Maintain chronological record of events and procedures of the resuscitation

2.5 Communicate relevant treatment information to other team members to aid in the continuity of care of the casualty

3. Perform post resuscitation duties

3.1 Accurately complete all relevant documentation

3.2 Provide documentation to team leader for authorisation

3.3 Organise ongoing casualty transfer in accordance with procedures

3.4 Refurbish resuscitation area in preparation for the next resuscitation

3.5 Participate in post event team debrief as applicable

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. Prepare for the role of scribe

1.1 Prepare resuscitation documentation prior to arrival of casualty

1.2 Prepare resuscitation area to receive the casualtyin accordance with preliminary clinical data obtained and direction from resuscitation team leader

1.3 Prepare own personal protective equipment in accordance with organisation policies and procedures

1.4 Follow guidance from team leader and resuscitation team members in accordance with prescribed role

2. Participate as a scribe in the resuscitation

2.1 Follow personal hygiene and infection control procedures

2.2 Ascertain casualty identity and history and record accurately

2.3 Record treatment information and casualty’s response to treatment

2.4 Maintain chronological record of events and procedures of the resuscitation

2.5 Communicate relevant treatment information to other team members to aid in the continuity of care of the casualty

3. Perform post resuscitation duties

3.1 Accurately complete all relevant documentation

3.2 Provide documentation to team leader for authorisation

3.3 Organise ongoing casualty transfer in accordance with procedures

3.4 Refurbish resuscitation area in preparation for the next resuscitation

3.5 Participate in post event team debrief as applicable

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:

completed the following tasks at least 3 times in line with governing regulations, trauma codes of practice and workplace procedures:

interpreted clinical data from multiple resources and accurately recorded details chronologically within emergency time constraints

recorded the following clinical information in a legible and clear manner:

medication

observations

assessment outcomes

interventions

referrals

pathology specimens

consumables (i.e. traceable with serial numbers)

operated/interpreted the following basic resuscitation equipment:

vital signs monitoring

intra-venous lines and fluids

monitors

used effective communication and teamwork skills:

active listening

questioning

feedback

information sharing

completed basic arithmetic calculations and recorded numbers

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:

legal, ethical and military requirements for scribe work:

codes of practice

duty of care

infection prevention and control

informed consent

mandatory reporting

privacy, confidentiality and disclosure

records management and documentation

rights and responsibilities of workers, employers and clients

specific information sources that inform work practice:

Primary clinical care manual (PCCM)

organisation/unit standard operating procedures

current operational mandate

work role boundaries – responsibilities and limitations

work health and safety

documentation used for casualty resuscitation purposes, including associated pathology requirements

personal protective equipment requirements

standard resuscitation equipment schedules and operation

clinical monitoring requirements for resuscitation

documentation processes relevant to receiving and resuscitating a casualty

medical terminology

basic anatomy and physiology of all body systems

general resuscitation protocols provided by Australian Resuscitation Council (ARC)

general pathology and investigative requirements pertaining to standard resuscitation processes

inter-departmental transfer requirements

role of other resuscitation team members and support services

storage and security requirement for personal effects (including weapons, explosives and pyrotechnics)