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Evidence Guide: HLTDEFHC403B - Conduct a clinical assessment

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

 

HLTDEFHC403B - Conduct a clinical assessment

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

Prepare for clinical assessment

  1. Assess environment for suitability to conduct a clinical assessment
  2. Select required equipment, consumables and documentation, check for serviceability and arrange for use
  3. Review relevant client history
  4. Use personal protective equipment as required
Assess environment for suitability to conduct a clinical assessment

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Select required equipment, consumables and documentation, check for serviceability and arrange for use

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Review relevant client history

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Use personal protective equipment as required

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Prepare client for clinical assessment

  1. Explain clinical assessment clearly and simply to the client
  2. Give client is given the opportunity to ask questions and discuss concerns
  3. Gain informed consent from client in accordance with clinical guidelines, organisation policies and procedures
  4. Assure and maintain confidentiality of client information
Explain clinical assessment clearly and simply to the client

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Give client is given the opportunity to ask questions and discuss concerns

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Gain informed consent from client in accordance with clinical guidelines, organisation policies and procedures

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Assure and maintain confidentiality of client information

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Obtain and record a medical history and client profile

  1. Ensure client is comfortable and positioned in a manner to avoid distractions
  2. Interview client to gather and convey information
  3. Obtain and record medical history and client profile according to clinical guidelines, organisation policies and procedures
Ensure client is comfortable and positioned in a manner to avoid distractions

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Interview client to gather and convey information

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Obtain and record medical history and client profile according to clinical guidelines, organisation policies and procedures

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Conduct a physical examination

  1. Follow personal hygiene and infection control procedures
  2. Measure and record vital signs in accordance with clinical guidelines, organisation policies and procedures
  3. Conduct examination using appropriate physical examination techniques according to clinical guidelines, organisation policies and procedures
  4. Record examination outcomes in accordance with clinical guidelines, organisation policies and procedures
Follow personal hygiene and infection control procedures

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Measure and record vital signs in accordance with clinical guidelines, organisation policies and procedures

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Conduct examination using appropriate physical examination techniques according to clinical guidelines, organisation policies and procedures

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Record examination outcomes in accordance with clinical guidelines, organisation policies and procedures

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Make a clinical assessment

  1. Make clinical assessment according to applied clinical reasoning and organisation policies and procedures
  2. Determine need for referral for extended physical examination and/or further diagnostic procedures
  3. Use information gathered through the clinical assessment to the develop treatment plan
  4. Arrange appropriate referral as required
Make clinical assessment according to applied clinical reasoning and organisation policies and procedures

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Determine need for referral for extended physical examination and/or further diagnostic procedures

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Use information gathered through the clinical assessment to the develop treatment plan

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Arrange appropriate referral as required

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Conclude clinical assessment

  1. Explain clinical assessment findings clearly and simply to the client
  2. Record clinical findings in a way that can be interpreted readily by others and according to clinic guidelines, organisation policies and procedures
  3. Clean and/or dispose of equipment and consumables in accordance with manufacturers' requirements and infection control policy
  4. Store equipment and consumables in accordance with organisation policy and procedures
Explain clinical assessment findings clearly and simply to the client

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Record clinical findings in a way that can be interpreted readily by others and according to clinic guidelines, organisation policies and procedures

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Clean and/or dispose of equipment and consumables in accordance with manufacturers' requirements and infection control policy

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Store equipment and consumables in accordance with organisation policy and procedures

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 confirm the ability to :

Resource implications

Assessment requires access to:

appropriate equipment

scenarios that reflect a range of clinical assessments that may be expected in the workplace

reference texts

local legal guidelines

Consistency in performance

Competency should be demonstrated over time with a range of clinical assessments that could be expected in the workplace

Context of assessment

Competency should be assessed in the workplace or in a simulated workplace

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

Related units:

This unit should be assessed in conjunction with this unit:

HLTDEFHC408B Provide treatments for common conditions

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:

Clinic and legislative guidelines

Clinical anatomy and physiology relevant to performing the examination and to evaluating results of the clinical assessment

Clinical tools and resources

Disease processes and affecting factors for a range of common conditions

Environmental causes of disease

Ethical and legal implications of examination

Further testing procedures

Interview techniques

Monitoring and maintaining appropriate medical equipment

Pathophysiology and disease process and classification relevant to making a clinical assessment and interpreting the findings

Purpose, method and sequencing of physical examinations

Referral procedure and recommended referral options

Relationship between physical findings, clinical diagnosis and treatment

Terminology correct to discipline

Essential skills:

It is critical that the candidate demonstrate the ability to:

Accurately record information in a systematic manner in accordance with clinic guidelines

Employ effective communication techniques during the client interview process

Identify and record signs and symptoms of disease

Interpret and understand the significance of findings

Know own limitations in clinical diagnosis sufficient to safeguard the client

Measure blood pressure, respiration rate, pulse rate and body temperature

Obtain and record a detailed medical history

Obtain problem focused information by performing inspection, palpation, auscultation, percussion, appropriate manoeuvres using appropriate examination equipment

continued ...

Essential skills (contd):

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:

Accurately record information

Correctly monitor, clean and maintain equipment

Correctly dispose of waste and sharps in accordance with workplace policy and taking into account opportunities to address waste minimisation, environmental responsibility and sustainable practice issues

Discuss and observe treatment protocols

Read and interpret medical reports

Relate examination outcome to symptomatology

Relate to a range of people from a range of cultural, linguistic, social and ethnic backgrounds, and a range of physical and intellectual abilities

Relate results of the test to symptomatology

Use available resources and prioritise workload

Use clinical tools and resources including the following:

equipment for measuring height and weight

examination table

glucometer and disposable lancets devices

goggles/protective eyewear

goose-neck lamp or other light source

measuring tape

nasal speculum

ophthalmoscope

otoscope

peak flow meter and disposable mouth pieces

penlight

percussion (reflex) hammer

sphygmomanometer

stethoscope

thermometer

timing device

Use medical reference

Use appropriate medical terminology

Use, monitor and maintain appropriate medical equipment

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.

Environment assessment may include:

Adequate lighting

Health care practitioner's specified needs

Suitable climate

Suitable client privacy

Equipment and consumables may include:

Equipment for measuring height and weight

Examination table

Glucometer and disposable lancets devices

Goggles/protective eyewear

Goose-neck lamp or other light source

Measuring tape

Nasal speculum

Ophthalmoscope

Otoscope

Peak flow meter and disposable mouth pieces

Penlight

Percussion (reflex) hammer

Skin marking pencil

Sphygmomanometer

Stethoscope

Thermometer

Timing device

Alcohol cleansing wipes

Cotton-tipped swab

Disposable gloves

Examination gowns

Gauze squares

Half-sheet for draping

Hazard bags for infection control

Instrument cleaning supplies

Sharps containers

Tongue depressors

Visual acuity charts

Confidentiality of client information may be ensured by:

Adherence to Privacy Act

Information disclosed to an appropriate person consistent with the responsibility of this position

Legal and ethical requirements

Secure location for written records

Treatment room with privacy

Medical history and client profile may include:

Current health information including:

habits (alcohol, tobacco, drugs, caffeine)

current medication being taken

exercise, sleep and dietary patterns

Past health history (pertinent to presenting complaint) such as:

past general health

accidents and disabling injuries

major acute and chronic illnesses

past allergies

past medications

Client biographical information

Presenting complaint

Present health and illness status, such as:

client summary and usual health

onset of current condition

progression since onset

body location, quality, quantity of discomfort

alleviating or aggravating factors (environment)

disability assessment

Relevant family health history

Review of systems:

physical background

functional limitations

sociological circumstance (home, work, etc)

psychological integrity

Clinical guidelines, organisation policies and procedures may include:

ADF nursing procedure manual

ADF treatment protocols

Clinical standards (state and national)

Industry professional bodies

Industry standards (state and national)

Organisation policy directives

Privacy Act

Relevant Australian standards

Measuring vital signs may include:

Following standardised procedures for infection control

Measuring blood pressure, respiration and pulse rates, and temperature

Personal hygiene and infection control procedures may include:

Australian and state standards and legislation

Industry standards

Organisation procedures

Standard precautions such as hand washing procedures

Direct instructions from supervisor

Physical examination techniques include:

Appropriate manoeuvres

Use of examination equipment

Auscultation

Inspection

Palpation

Percussion

Applied clinical reasoning includes:

Collecting clinical data (interview, medical history, physical examination, clinical measurements)

Organising data (recognising key diagnostic data, validating data, clustering data into a clinical pattern)

Making the clinical assessment

Linking the assessment to the treatment plan

Need for referral may include:

Need for higher medical diagnostic information or procedures

Signs of notifiable disease

Suspected dangerous pathology

Unknown symptom complex or condition

Identified condition outside of own scope of management