Perform clinical assessment and contribute to planning nursing care

Formats and tools

Unit Description
Reconstruct the unit from the xml and display it as an HTML page.
Assessment Tool
an assessor resource that builds a framework for writing an assessment tool
Assessment Template
generate a spreadsheet for marking this unit in a classroom environment. Put student names in the top row and check them off as they demonstrate competenece for each of the unit's elements and performance criteria.
Assessment Matrix
a slightly different format than the assessment template. A spreadsheet with unit names, elements and performance criteria in separate columns. Put assessment names in column headings to track which performance criteria each one covers. Good for ensuring that you've covered every one of the performance criteria with your assessment instrument (all assessement tools together).
Wiki Markup
mark up the unit in a wiki markup codes, ready to copy and paste into a wiki page. The output will work in most wikis but is designed to work particularly well as a Wikiversity learning project.
Evidence Guide
create an evidence guide for workplace assessment and RPL applicants
Competency Mapping Template
Unit of Competency Mapping – Information for Teachers/Assessors – Information for Learners. A template for developing assessments for a unit, which will help you to create valid, fair and reliable assessments for the unit, ready to give to trainers and students
Observation Checklist
create an observation checklist for workplace assessment and RPL applicants. This is similar to the evidence guide above, but a little shorter and friendlier on your printer. You will also need to create a seperate Assessor Marking Guide for guidelines on gathering evidence and a list of key points for each activity observed using the unit's range statement, required skills and evidence required (see the unit's html page for details)

Self Assessment Survey
A form for students to assess thier current skill levels against each of the unit's performance criteria. Cut and paste into a web document or print and distribute in hard copy.
Moodle Outcomes
Create a csv file of the unit's performance criteria to import into a moodle course as outcomes, ready to associate with each of your assignments. Here's a quick 'how to' for importing these into moodle 2.x
Registered Training Organisations
Trying to find someone to train or assess you? This link lists all the RTOs that are currently registered to deliver HLTENN003, 'Perform clinical assessment and contribute to planning nursing care'.
Google Links
links to google searches, with filtering in place to maximise the usefulness of the returned results
Books
Reference books for 'Perform clinical assessment and contribute to planning nursing care' on fishpond.com.au. This online store has a huge range of books, pretty reasonable prices, free delivery in Australia *and* they give a small commission to ntisthis.com for every purchase, so go nuts :)


Elements and Performance Criteria

ELEMENT

PERFORMANCE CRITERIA

Elements define the essential outcomes

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

1. Collect and interpret health data.

1.1 Introduce self and explain processes before commencing nursing assessment activities.

1.2 Gather information from the person, or their family or carer if the person is unable to communicate, using culturally appropriate strategies.

1.3 Document the person’s gender, age and cultural, religious or spiritual data when undertaking the preliminary health assessment.

1.4 Measure the person’s vital signs using appropriate biomedical equipment according to the acuity of care and the person’s physical characteristics.

1.5 Perform clinical measurements and assessments when undertaking the clinical nursing assessment, identifying the person’s developmental state.

1.6 Record objectively the person’s lifestyle patterns, health history, current health practices, coping mechanisms, issues and needs.

1.7 Clarify the emotional and physical needs of the family or carer in supporting the person.

1.8 Use critical thinking to interpret objective and subjective data from the assessment, and determine if the data is or is not within normal range.

1.9 Communicate immediately all deterioration concerns about the person to registered nurse.

2. Undertake admission and discharge procedures for a person.

2.1 Collect data from the person for admission and discharge planning as required by organisation policy and procedures.

2.2 Contribute to nursing assessment by documenting the person’s values and attitudes regarding health care, and any issues they may be experiencing that may impact on a timely discharge.

2.3 Identify community support services and resources to assist in planning for discharge.

2.4 Ensure the person has all discharge planning requirements including General Practitioner appointment and any medications and referrals.

3. Contribute to planning the nursing care of a person.

3.1 Analyse a person’s health history and clinical assessment to identify risks and likely impacts on activities of daily living, and the health care that is required.

3.2 Outline a plan of care using a problem-solving approach and ensuring strategic care planning appropriate to the person’s needs.

3.3 Clarify and reflect the person’s interests and physical, emotional and psychosocial needs in care planning and documentation.

4. Contribute to ongoing development of individual nursing care plans.

4.1 Analyse, using critical thinking, the rationale for specific decisions and the course of action taken in the person’s nursing care plan.

4.2 Confirm with the person, family or carer that planned nursing care provided reflects the person’s needs including their uniqueness, culture, religious beliefs and management of stress.

4.3 Ensure nursing care plan is based on principles of best practice and risk assessment.

4.4 Raise with the registered nurse or interdisciplinary health care team any conflicts between the nursing care plan and an already prescribed plan of care for the person.