Unit of competency

Modification History

Release	Comments
Release 2	Updated: assessor requirements statement foundation skills lead in statement licensing statement modification history to reflect 2012 standards Equivalent outcome.
Release 1	This version was released in HLT Health Training Package release 1.0 and meets the requirements of the 2012 Standards for Training Packages. Significant changes to elements and performance criteria. New evidence requirements for assessment, including volume and environment requirements

Application

This unit describes the skills and knowledge required to initiate, undertake and interpret findings from a range of clinical assessments, tests and procedures to determine the physical wellbeing of a client. Findings of these assessments will be used as the basis of a health care plan – the skills and knowledge to plan, implement and monitor a health care plan are detailed in HLTAHW018 Plan, implement and monitor health care plan in a primary health care context.

This unit applies to those Aboriginal and/or Torres Strait Islander Health Workers providing a range of primary health care services to Aboriginal and/or Torres Strait Islander clients and communities.

The skills in this unit must be applied in accordance with Commonwealth and State/Territory legislation, Australian/New Zealand standards and industry codes of practice.

Elements and Performance Criteria

ELEMENT	PERFORMANCE CRITERIA
Elements define the essential outcomes.	Performance criteria specify the level of performance needed to demonstrate achievement of the element.
1. Initiate health assessment	1.1 Seek to establish trust with the client, through active promotion of and strict adherence to confidentiality 1.2 Obtain client’s history using effective, culturally appropriate and safe communication skills 1.3 Seek additional health-related information from the client’s family and/or carer(s) and relevant community members with the client’s consent 1.4 Consult relevant allied professionals and available documentation in relation to the health of the client 1.5 Document all information about the client in accordance with organisational procedures and policies
2. Assess client’s physical health	2.1 Explain the process and rationale of each examination and test to the client 2.2 Perform physical and clinical assessments in line with organisational policies and procedures and with respect for community values, beliefs and gender roles 2.3 Measure vital signs and identify significant variation from normal ranges and refer to senior staff member as required 2.4 Use correct procedures and take precautions to collect and send specimens for pathology testing 2.5 Accurately record all outcomes of assessments in accordance with organisational procedures and policies 2.6 Identify non-clinical factors potentially responsible for significant variations from normal ranges and make repeat assessments
3. Interpret and confirm health assessment findings	3.1 Accurately identify a range of signs and symptoms of health conditions 3.2 Recognise signs and symptoms of potentially serious underlying conditions and refer to senior health staff for advice 3.3 Interpret the significance of health assessment findings in the context of the holistic health of the client 3.4Identify any significant variations from normal range on the basis of health assessment data 3.5 Consult other team members to confirm interpretations and clarify implications and significance of findings 3.6 Seek assistance when findings are unclear or outside limits of own authority 3.7 Report notifiable diseases identified to supervisor and/or an appropriate authority, in line with jurisdictional requirements 3.8 Initiate action in relation to any issues requiring mandatory reporting according to procedural and legislative requirements 3.9 Accurately document client history and examination findings in client’s file
4. Summarise and present findings	4.1 Provide client with information about findings of physical examination 4.2 Check client understanding of information through appropriate questioning 4.3 Provide client with information relevant to promoting and maintaining their health in a way they readily understand 4.4 Support client to take a self-care approach to health in line with individual needs and organisational and community requirements 4.5 Document and refer as necessary all discussions with client and/or significant others in client file according to organisational procedures and policies

Foundation Skills

The Foundation Skills describe those required skills (language, literacy, numeracy and employment skills) that are essential to performance.
Numeracy	in order to use and interpret readings of medical equipment including haemoglobinometer, tape measure, sphygmomanometer, scales, thermometers, glucometer, peak expiratory flow rate meters in order to measure vital signs, including temperature, pulse, blood pressure and respiratory rate
Reading	to interpret various pieces of written information regarding the client’s health, including referrals, test outcomes and reports

Other foundation skills essential to performance are explicit in the performance criteria of the unit.

Unit Mapping Information

No equivalent unit.

Links

Companion Volume implementation guides are found in VETNet - https://vetnet.gov.au/Pages/TrainingDocs.aspx?q=ced1390f-48d9-4ab0-bd50-b015e5485705

Assessment requirements

Modification History

Release	Comments
Release 2	Updated: assessor requirements statement foundation skills lead in statement licensing statement modification history to reflect 2012 standards Equivalent outcome.
Release 1	This version was released in HLT Health Training Package release 1.0 and meets the requirements of the 2012 Standards for Training Packages. Significant changes to elements and performance criteria. New evidence requirements for assessment, including volume and environment requirements.

Performance Evidence

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:

• assessed and monitored the physical wellbeing of at least five Aboriginal and/or Torres Strait Islander adults and children by:

- establishing a relationship of trust with clients and significant others

- taking a detailed history of the client

- explaining assessment methods and procedures to client and/or significant others

- observing and assessing client’s health, using appropriate tests and medical instrumentation

- recording observations

- questioning, assessing and monitoring client’s health status, issues and needs

- reviewing effectiveness of health care strategies and making appropriate revisions, taking prior history into consideration

- summarising and presenting findings in line with client needs and workplace requirements

- maintaining client records and upholding client confidentiality

- communicating with client’s family and/or significant others as required

- gaining informed consent to conduct assessment

- taking, considering and recording relevant details of client’s history (including body language)

- complying with and enforcing infection control guidelines

- using a structured approach to assessment

- interpreting common pathology tests

- taking full responsibility for assessment findings.

Knowledge Evidence

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:

• organisational policies and procedures and legislation or regulations relating to:

- client confidentiality

- referral, including various levels of urgency, and follow-up of client

- mandatory reporting

- notifiable communicable diseases

- limits of own ability and authority

- reporting procedures

- documentation

• key elements of comprehensive and accurate physical, social/emotional and mental health assessment
• anatomy/physiology and associated microbiology, pathophysiology (disease processes) and pharmacology including:

- respiratory system

- circulatory system

- integumentary system

- digestive system

- genitourinary system

- endocrine system

- musculoskeletal system

- nervous system

- reproductive systems

• pathophysiology associated with these systems, including:

- acute chronic condition and conditions associated with a specific body system

- injuries

- wounds

- arthritis

- inflammation

- impact of alcohol and drugs

• pharmacology to address pathophysiology, including:

- medications and forms of administration

- antibiotics

- analgesics

- contraindications

- complications

- psychiatric medications

- oral hypoglycaemics

- insulin

• procedures for health tests and ‘normal’ range of test outcomes, including:

- blood pressure (for adults and children)

- temperature

- pulse rate

- respiratory and peak flow rates

- height and weight

- components of urine

- near vision and pinhole visual acuity testing

• visual examination of eye and ear
• blood glucose (sugar) and haemoglobin levels
• in relation to cardiovascular diseases:

- the concept of ‘cardiovascular risk factors’, the significance of an individual having multiple risk factors and the concept of ‘high absolute risk’

- the importance of reduction of saturated fats and sugar-sweetened soft drinks, increased physical activity and smoking cessation in reducing the risk of heart and kidney disease in Aboriginal and/or Torres Strait Islander populations

• in relation to diabetes mellitus:

- basic pathophysiology of type II contrasted with type I diabetes mellitus

- complications of diabetes (including heart disease and stroke; renal failure; retinal damage and blindness; nerve damage and infection resulting in amputation; impotence)

- the main elements of the ‘diabetes check up’

- the procedure for taking retinal photographs

- basic anatomical features and abnormalities on a retinal photograph

- the content of client education for diabetes covering diet, physical activity, foot-care, and use of diabetes medicines

• in relation to chronic renal disease:

- basic pathophysiology of chronic renal failure (causes, body systems affected, natural history)

- factors which may worsen or accelerate renal failure (including: high blood pressure, anti-inflammatory drugs, poor diabetes control, dehydration, high protein diet)

- clinical features of advanced renal failure

- the importance of early detection of renal disease in efforts to defer or prevent end-stage renal failure

- options for treatment of end-stage renal failure (haemodialysis, chronic ambulatory peritoneal dialysis, transplant).

• familiarity with a range of other common chronic conditions in Aboriginal and/or Torres Strait Islander populations:

- chronic liver disease – causes, clinical features and principles of management (including hepatitis B, hepatitis C, alcoholic liver disease and cirrhosis)

- chronic obstructive lung disease, relationship to smoking and principles of management

• basic nature, management and associated risk factors for common diseases
• commonly (including complete blood tests and urine analysis) and specifically requested pathology tests and the correct methods of collection, storage and transport of specimens
• the clinical significance of abnormal findings on pathology tests with particular reference to use of medicines
• knowledge of care planning and self-management support tools
• relevant criteria for evaluation of effectiveness of care plan
• features of chronic illness, including:

- complex causality

- multiple risk factors

- long latency periods

- a prolonged course of illness

- functional impairment or disability

• specific chronic conditions affecting Aboriginal and/or Torres Strait Islander clients and communities, including:

- cardiovascular disease

- diabetes

- cancer

- chronic respiratory disease

- chronic kidney disease

- asthma

- arthritis

- oral disease

• determinants of chronic conditions, including:

- smoking

- physical activity

- nutrition

- alcohol intake

- use of illicit drugs

- obesity, weight and waist circumference

- unsafe sexual practices

- genetic factors

• linkages between conditions such as diabetes and eye health, nutrition and hearing, etc.

Assessment Conditions

Skills must be demonstrated working:

• in a health service or centre
• as part of a multidisciplinary primary health care team
• with Aboriginal and/or Torres Strait Islander clients and communities.

In addition, simulations and scenarios must be used where the full range of contexts and situations cannot be provided in the workplace or may occur only rarely. These are situations relating to emergency or unplanned procedures where assessment in these circumstances would be unsafe or is impractical.

Simulated assessment environments must simulate the real-life working environment where these skills and knowledge would be performed, with all the relevant equipment and resources of that working environment.

This may include medical equipment including but not limited to haemoglobin meter, tape measure, sphygmomanometer, scales, thermometers, glucometer, peak expiratory flow rate meters.

Assessors must satisfy the Standards for Registered Training Organisations (RTOs) 2015/AQTF mandatory competency requirements for assessors.

Assessment must be undertaken by a workplace assessor who has expertise in this unit of competency and who is:

• an Aboriginal and/or Torres Strait Islander Health Worker

or:

• accompanied by an Aboriginal and/or Torres Strait Islander person who is a recognised member of the community with experience in primary health care.

Links

Companion Volume implementation guides are found in VETNet - https://vetnet.gov.au/Pages/TrainingDocs.aspx?q=ced1390f-48d9-4ab0-bd50-b015e5485705