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Unit of competency details

HLTHOM604C - Perform clinical screening examination and assessment (Release 1)

Summary

Usage recommendation:
Deleted
The Deleted usage recommendation was implemented on 13 June 2017 to describe training components that have no replacement. Enrolments in training components and statements of attainment or qualifications issued before 13 June 2017 are valid. For any components marked as deleted after 13 June 2017, the applicable transition/teach-out periods apply. For specific questions regarding the enrolment, delivery or issuance of a statement of attainment/qualification, please contact your training regulator.
Mapping:
MappingNotesDate
DeletedDeleted from HLT07 Health Training Package07/Dec/2015
Supersedes and is equivalent to HLTHOM4A - Perform clinical screening examination and assessmentUnit updated in V4 - equivalent competency outcome24/Mar/2011

Releases:
ReleaseRelease date
1 1 (this release) 25/Mar/2011

Classifications

SchemeCodeClassification value
ASCED Module/Unit of Competency Field of Education Identifier 061999 Complementary Therapies, N.e.c.  

Classification history

SchemeCodeClassification valueStart dateEnd date
ASCED Module/Unit of Competency Field of Education Identifier 061999 Complementary Therapies, N.e.c.  04/Nov/2011 
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Modification History

Not Applicable

Unit Descriptor

Descriptor 

This unit of competency describes the skills and knowledge required to perform screening examination of vital signs and physical condition and to make a screening assessment of the client

Procedures are governed by the application of local legislation

Application of the Unit

Application 

This unit applies to work in homœopathy

Licensing/Regulatory Information

Not Applicable

Pre-Requisites

Not Applicable

Employability Skills Information

Employability Skills 

This unit contains Employability Skills

Elements and Performance Criteria Pre-Content

Elements define the essential outcomes of a unit of competency.

The Performance Criteria specify the level of performance required to demonstrate achievement of the Element. Terms in italics are elaborated in the Range Statement.

Elements and Performance Criteria

ELEMENT 

PERFORMANCE CRITERIA 

1. Observe client's vital signs

1.1 Observe client's demeanour and appearance

1.2 Organise examination 

1.3 Communicate examination procedures  to client

1.4 Undertake examination for vital signs

2. Conduct screening physical examination according to local legislative guidelines

2.1 Conduct screening examination when needed to ensure client safety and elicit signs of disease

2.2 Identify areas of investigation 

2.3 Organise examination 

2.4 Communicate examination procedures  to client

2.5 Conduct examination using appropriate techniques , equipment and supplies 

2.6 Conduct examination according to clinic guidelines, local regulation and legislative requirements

3. Make a screening assessment and refer for further examination

3.1 Conduct extended interview 

3.2 Make a screening assessment  to ensure client safety

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

3.4 Arrange referral as needed

4. Monitor and record findings

4.1 Record all findings and file in accordance with clinic guidelines

4.2 Monitor outcomes of referrals 

4.3 Treat all documentation confidentially

5. Discuss outcomes of referral with the client

5.1 Discuss rationale of the medical diagnosis/prognosis with the client

5.2 Respond to client enquiries using language the client understands

5.3 Discuss referral and collaborative options with the client if necessary

Required Skills and Knowledge

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:

  • Anatomy and physiology relevant to evaluating results of the screening assessment
  • Basic nutritional requirements for the various ages and stages of life
  • Clinic and local legislative guidelines relevant to assessment techniques
  • Clinical anatomy and physiology relevant to performing the examination
  • Disease processes and affecting factors for a range of common diseases
  • Ethical and legal implications of enquiry and examination
  • Further testing procedures
  • Homœopathic tools and resources
  • Interview techniques
  • Normal anatomy in relation to diagnostic imaging procedures
  • Pathophysiology and disease process and classification relevant to making a screening assessment and interpreting the findings
  • Pathophysiology and disease process relevant to performing the examination
  • Referral procedure and recommended referral options
  • Relevant anatomy and pathophysiology to competently collect specimens and interpret results
  • Relevant medical equipment
  • Terminology correct to discipline
  • The environmental causes of disease
  • The mode of presentation of potentially fatal and emergency medical and surgical conditions
  • The practitioner's own limitations in clinical diagnosis and therapy sufficient to safeguard the client
  • The purpose, method and sequencing of screening physical examinations
  • The relationship between physical findings, clinical diagnosis and homœopathic prescribing
  • The relationship between physical findings, clinical diagnosis and homœopathic prescribing
  • The relationship between physical findings, diagnosis and homœopathic prescribing

Essential skills :

It is critical that the candidate demonstrate the ability 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
  • Accurately record information in a systematic manner in accordance with clinic guidelines
  • Address time management requirements during consultation
  • Communicate effectively to gain required information
  • Correctly dispose of waste and sharps in accordance with workplace policy
  • Correctly monitor, clean and maintain equipment
  • Demonstrate communication skills
  • Discuss and observe treatment protocols
  • Identify and record signs and symptoms of disease
  • Identify clinical signs of nutritional imbalance
  • Interpret and understand the significance of findings
  • Interpret medical test data such as urine, blood test data, faecal and biopsy reports
  • Obtain problem focused information by performing inspection, palpation, auscultation, percussion and appropriate manoeuvres
  • Read and interpret medical reports
  • Read and interpret medical test results or documents
  • Recognise when specimen collection is required
  • Relate results of the test to homœopathic symptomatology
  • Take into account opportunities to address waste minimisation, environmental responsibility and sustainable practice issues
  • Use homœopathic tools and resources
  • Use medical reference texts including homœopathic and western medicine texts
  • Use terminology correct to discipline
  • Use, monitor and maintain appropriate medical equipment

Evidence Guide

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 :

  • The individual being assessed must provide evidence of specified essential knowledge as well as skills
  • Observation of performance in the workplace or a simulated workplace (defined as a supervised clinic) is essential for assessment of this unit
  • Consistency of performance should be demonstrated over the required range of situations relevant to the workplace
  • Where, for reasons of safety, space, or access to equipment and resources, assessment takes place away from the workplace, the assessment environment should represent workplace conditions as closely as possible
  • Assessment of sole practitioners must include a range of clinical situations and different client groups covering at minimum, age, culture and gender
  • Assessment of sole practitioners must consider their unique workplace context, including:
  • interaction with others in the broader professional community as part of the sole practitioner's workplace
  • scope of practice as detailed in the qualification and component competency units
  • holistic/integrated assessment including:
  • working within the practice framework
  • performing a health assessment
  • assessing the client
  • planning treatment
  • providing treatment

Context of and specific resources for assessment :

  • An appropriately stocked and equipped clinic or simulated clinic environment
  • Reference texts
  • Local legal guidelines
  • Appropriate assessment environment
  • Skilled assessors

Method of assessment 

  • Observation in the work place
  • Written assignments/projects or questioning should be used to assess knowledge
  • Case study and scenario as a basis for discussion of issues and strategies to contribute to best practice
  • Examples of assessment notes
  • Clinical skills involving direct client care are to be assessed initially in a simulated clinical setting (laboratory). If successful, a second assessment is to be conducted during workplace application under direct supervision

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 the following related competency units:

  • HLTCOM404C Communicate effectively with clients
  • HLTHIR301B Communicate and work effectively in health
  • HLTHOM601C Apply homœopathic diagnostic framework
  • HLTIN301C Comply with infection control policies and procedures

Range Statement

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.

Examination is organised means :

  • Consent is obtained from a parent/ guardian/ caregiver prior to commencing a physical examination of a minor or an adult under guardianship
  • Equipment is arranged
  • Equipment is checked/calibrated so that it is in good working order
  • Client and examiner are positioned
  • Examination is sequenced for efficiency and client and examiner comfort

Procedures are communicated may include :

  • Informing client of procedures to be carried out
  • Obtaining client consent at each stage of examination
  • An appropriate adult (parent/guardian/caregiver) must be present during examination of a minor or an adult under guardianship

Examination for vital signs must include competency in :

  • Measuring blood pressure, respiration and pulse rates, and temperature
  • Performing standardised sequence of examination
  • Using required equipment, including
  • sphygmomanometer
  • stethoscope
  • timing device
  • thermometer
  • peak flow meter and disposable mouth pieces, if required
  • Following standardised procedures for infection control

Areas of investigation may include :

  • Full screening examination
  • General appearance and vital signs
  • Skin
  • Head, eyes, ears, nose, oral cavity and throat
  • Neck
  • Breasts and axillae
  • Thorax and lungs
  • Heart and great vessels
  • Abdomen
  • Limbs
  • Neurological system
  • Lower back
  • Cardiovascular system
  • Reproductive system
  • Respiratory system
  • Gastrointestinal system
  • Urinary system
  • Endocrine system

Techniques include :

  • Inspection
  • Palpation
  • Auscultation
  • Percussion
  • Appropriate manoeuvres

Equipment must include :

  • Thermometer
  • Sphygmomanometer
  • Stethoscope
  • Timing device
  • Peak flow meter and disposable mouth pieces
  • Examination table
  • Otoscope
  • Penlight
  • Percussion (reflex) hammer
  • Measuring tape
  • Equipment for measuring height and weight
  • Goose-neck lamp or other light source
  • And may include:
  • Ophthalmoscope
  • Tuning fork(s)
  • Nasal speculum
  • Skin marking pencil
  • Glucometer and disposable lancets devices

Supplies required must include :

  • Half-sheet for draping
  • Examination gowns
  • Disposable gloves
  • Tongue depressors
  • Cotton-tipped swab
  • Gauze squares
  • Medi alcohol swabs
  • Hazard bags for infection control
  • Sharps containers
  • Instrument cleaning supplies

And may include :

  • Visual acuity charts
  • Goggles/protective eyewear

Extended interview may include :

  • Extended history taking
  • Formulating clinical diagnostic hypothesis
  • Data gathering and hypothesis testing
  • Identifying role of past medical history
  • Identifying role of client profile
  • Relating signs and symptoms to diagnostic areas using a standard system of clinical evaluation

Screening assessment must imply one of the following :

  • The need for further examination or investigation
  • The need for further evaluation of the signs and symptoms to establish a clinical diagnosis
  • A definite clinical diagnosis
  • A dangerous pathology or psychiatric condition
  • A condition which can be safely and satisfactorily managed by the practitioner

Screening assessment involves :

  • Establishing expected normal course of disease including:
  • natural duration of disease
  • progress, extension, radiation and pace
  • probability of remission

The need for referral may include :

  • Suspected dangerous pathology
  • Unknown symptom complex or condition
  • Signs of notifiable disease
  • Need for medical diagnostic information

Further diagnostic procedures may include :

  • Diagnostic laboratory tests
  • Diagnostic imaging
  • Referral to a diagnostician

Outcomes of referrals includes :

  • Ascertaining that diagnostic procedures or extended examination has been carried out by the appropriate practitioner
  • Assessing and analysing the data arising out of the referral

Unit Sector(s)

Not Applicable