Unit of competency details

HLTAHW401B - Assess client's physical well being (Release 1)


ReleaseStatusRelease date
1 1 (this release)Current 25/Mar/2011

Usage recommendation:
Is superseded by HLTAHW016 - Assess client's physical wellbeingNew unit in HLT Health Training Package Release 1.0. Significant changes to elements and performance criteria.New evidence requirements for assessment, including volume and environment requirements 30/Jun/2013

Training packages that include this unit


SchemeCodeClassification value
ASCED Module/Unit of Competency Field of Education Identifier 061305 Indigenous Health  

Classification history

SchemeCodeClassification valueStart dateEnd date
ASCED Module/Unit of Competency Field of Education Identifier 061305 Indigenous Health  04/Nov/2011 
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Modification History

Not Applicable

Unit Descriptor

Unit Descriptor 

This unit deals with the skills and knowledge required to initiate, undertake, interpret findings from a range of clinical assessments, tests and procedures as a member of a multi-disciplinary team working with Aboriginal and/or Torres Strait Islander communities

Application of the Unit


This unit may be applied by those working individually (eg. in isolated practice) or as part of a team
(eg. associated with a clinic or hospital)

It is imperative that cultural issues, including gender and kinship issues, are respected in the delivery, assessment and application of this competency unit

Licensing/Regulatory Information

Not Applicable


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



1. Initiate health assessment 

1.1 Seek to establish a relationship of trust with the client, through active promotion of and strict adherence to confidentiality

1.2 Consider and respect Aboriginal or Torres Strait Islander community values, beliefs and gender roles when undertaking physical examination

1.3 Obtain an accurate history  from the client, using available information from verbal, written and non-verbal sources

1.4 Seek additional health-related information from the client , their family and/or carer(s) and relevant community members

1.5 Consult relevant allied professionals and available documentation in relation to the health of the client

1.6 Initiate clinical tests in response to a range of triggers in line with organisation policies and in agreement with the client

1.7 Initiate health assessment in line with organisation policies and procedures

2. Undertake client observation and clinical tests 

2.1 Consider range of factors that may impact on client health when undertaking clinical assessment

2.2 Undertake specified clinical assessments using structured methods supported by a depth of knowledge and experience

2.3 Ensure client observations and conduct of clinical tests are underpinned by standard protocols

2.4 Conduct clinical assessment in accordance with organisation policies and procedures and occupational health and safety requirements

2.5 Use medical equipment  effectively and maintain in accordance with organisation policies and manufacturer's guidelines/ specification

2.6 Measure vital signs  and identify significant variation from normal

2.7 Use correct procedures to collect and send specimens for pathology testing , in line with standard clinical protocols, organisation procedures and universal precautions

2.8 Conduct physical examinations in accordance with standard infection control and occupational health and safety requirements

2.9 Provide clients with information about each examination/test to be undertaken and the rationale for its use

3. Assess client's physical health

3.1 Accurately identify a range of signs and symptoms of health conditions  through health assessment methods in line with standard protocols

3.2 Identify non -clinical factors potentially responsible for significant variations from normal and make repeat  assessments

3.3 Recognise signs/symptoms of potentially serious underlying conditions  and refer to senior health staff for advice

4. Clarify health assessment findings

4.1 Clearly describe health assessment findings and interpret their significance in the context of the holistic health of the client

4.2 Consult other team members to check / confirm interpretation and to clarify implications and significance of findings

4.3 Identify any significant variations from normal on the basis of health assessment data

4.4 Seek assistance when findings are unclear or outside limits of own authority

4.5 Report notifiable diseases identified to supervisor and/or an appropriate authority in line with jurisdictional requirements

5. Summarise and present findings

5.1 Accurately document client history and examination findings in client's file in accordance with organisation policies and procedures

5.2 Present client history and findings of physical examination as determined by organisation policies and procedures

5.3 Identify common uncomplicated health conditions based on history, physical examination and available information about presenting problem

5.4 Promptly refer to senior health staff for advice on serious or potentially serious health problems as determined in organisation protocols

5.5 Provide client with information about findings of physical examination in line with organisation policies and procedures

5.6 Provide client with information relevant to promoting and maintaining health in a way they understand readily

5.7 Check client understanding of information through appropriate questioning

5.8 Provide health information  to client in appropriate language, supported by visual and other aids as required

5.9 Support client to take a self-care approach to health in line with individual needs and organisation and community requirements

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:

  • Organisation policies and procedures relating to client confidentiality
  • Key elements of comprehensive and accurate physical, social/emotional and mental health assessment
  • Common presenting problems and procedures and protocols of relevant action to be taken
  • Indicators/requirements for initiating health assessment (specific to organisation, region, community)
  • Underpinning knowledge of anatomy/physiology; microbiology, pathophysiology (disease processes) and pharmacology related to:
  • circulatory system (including blood pressure, the pulse)
  • respiratory tract
  • male and female urinary and genital tracts
  • gastrointestinal tract
  • skeletal system
  • nervous system
  • endocrine system
  • the ear
  • the skin
  • the eye
  • components of mouth and tooth structure
  • Basic knowledge of micro-organisms which are pathological to humans and the conditions which they precipitate
  • Correct procedures and protocols used:
  • to assess common client presentations
  • during health assessment to limit infection and cross infection
  • '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
  • standard eye tests
  • visual examination of eye and ear
  • blood glucose (sugar) and haemoglobin levels

continued  ...

Essential knowledge  (continued ):

  • Nature and associated signs/symptoms and implications of range of test outcomes for relevant health conditions, including:
  • respiratory conditions
  • genito-urinary conditions
  • gastrointestinal problems
  • ear conditions
  • eye problems
  • sexually transmitted infections
  • Basic nature, management and associated risk factors for common diseases, including:
  • cardiovascular diseases
  • rheumatic fever and rheumatic heart disease
  • diabetes
  • infectious conditions
  • renal disease
  • Limits of own ability and authority and when to refer or seek assistance
  • Knowledge of specific pathology tests, and the correct methods of collection, storage and transport of specimens; significance of results
  • Knowledge relating to pregnancy and birthing, including:
  • mechanics of pregnancy and birthing
  • impact of smoking, alcohol and poor nutrition in pregnancy
  • recognition of common or potentially serious pregnancy problems (eg. premature labour, bleeding, high BP)
  • Knowledge of reproductive health, including:
  • physiology of conception
  • recognition of sexually transmitted infections (STIs)
  • contraceptive options
  • Links between environment and health, including:
  • crowding
  • clean water
  • sanitation
  • food contamination
  • insect vectors
  • Key elements of accurate reporting via radio/ telephone, in writing and during case discussion

continued  ...

Essential knowledge  (continued ):

  • Commonly requested pathology tests and abbreviations, including:
  • full blood examination and ESR
  • random and fasting blood glucose (sugar) level
  • glycated haemoglobin
  • electrolytes and creatinine
  • liver function tests
  • lipid tests
  • thyroid function tests
  • iron studies
  • cardiac enzymes
  • urinary albumin-creatinine ratio
  • tests for sexually transmitted infections
  • microscopy, culture and sensitivities
  • The clinical significance of abnormal findings on common pathology tests with particular reference to use of medicines

Essential skills :

It is critical that the candidate demonstrate the ability to:

  • Work independently and consistently in delivering primary health care services to Aboriginal and/or Torres Strait Islander clients, including:
  • detailed client observation, questioning and assessment to determine the client's health status, issues and needs
  • summary and presentation of findings in line with client needs and workplace requirements
  • maintenance of client records and upholding client confidentiality

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:

  • Communicate effectively and establish a relationship of trust with clients and significant others
  • Conduct accurate and effective client assessment, including:
  • take, consider and record relevant details of client's history (including body language)
  • observe and assess client's health, using appropriate tests and medical instrumentation
  • comply with (and enforce) infection control guidelines
  • use a structured approach to assessment
  • interpret common pathology tests
  • take full responsibility for assessment findings

continued  ...

Essential skills :

  • Carry out clinical procedures safely, effectively and within guidelines
  • Elicit relevant information from client or documents
  • Explain assessment methods and procedures to client
  • Identify situations when assistance is required
  • Initiate appropriate actions in response to assessment in line with organisation procedures and protocols for commonly presented health conditions
  • Interpret available documented health information
  • Interpret, document and report detailed findings of simple routine assessments.
  • Interpret, document and report findings of standard pathology tests
  • Make timely and appropriate referrals, providing accurate and relevant details to clients and referral agencies
  • Recognise signs/symptoms of:
  • uncontrolled pain
  • potentially serious underlying conditions
  • Reflect on and improve own level and application of skills and knowledge to achieve desirable outcomes and maintain own capabilities
  • Take into account opportunities to address waste minimisation, environmental responsibility and sustainable practice issues
  • Use appropriate procedures, tests and protocols to conduct routine health assessments for Aboriginal and/or Torres Strait Islander clients (adults and children)

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 of assessment :

  • The individual being assessed must provide evidence of specified essential knowledge as well as skills
  • 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

Conditions of assessment :

This unit includes skills and knowledge specific to Aboriginal and/or Torres Strait Islander culture

Assessment must therefore be undertaken by a workplace assessor who has expertise in the unit of competency or who has the current qualification being assessed and who is:

  • Aboriginal or Torres Strait Islander him/herself


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

Context of assessment :

Competence should be demonstrated working individually, under supervision or as part of a primary health care team working with Aboriginal and/or Torres Strait Islander clients

Assessment should replicate workplace conditions as far as possible

Related units :

This unit may be assessed independently or in conjunction with other units with associated workplace application

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.

Cultural respect 

This competency standard supports the recognition, protection and continued advancement of the inherent rights, cultures and traditions of Aboriginal and Torres Strait Islander peoples

It recognises that the improvement of the health status of Aboriginal and Torres Strait Islander people must include attention to physical, spiritual, cultural, emotional and social well being, community capacity and governance

Its application must be culturally sensitive and supportive of traditional healing and health, knowledge and practices

Community control 

Community participation and control in decision-making is essential to all aspects of health work, and the role of the health worker is to support the community in this process


Supervision must be conducted in accordance with prevailing state/territory and organisation legislative and regulatory requirements

References to supervision may include either direct or indirect supervision of work by more experienced workers, supervisors, managers or other health professionals

A person at this level should only  be required to make decisions about clients within the organisation's standard treatment protocols and associated guidelines

Legislative requirements 

Federal, state or territory legislation may impact on workers' practices and responsibilities. Implementation of the competency standards should reflect the legislative framework in which a health worker operates. It is recognised that this may sometimes reduce the application of the Range of Variables in practice. However, assessment in the workplace or through simulation should address all essential skills and knowledge across the Range of Variables

Aboriginal and/or Torres Strait Islander Health Workers may be required to operate in situations that do not constitute "usual practice" due to lack of resources, remote locations and community needs. As a result, they may need to possess more competencies than described by "usual practice circumstances"

Under all circumstances, the employer must enable the worker to function within the prevailing legislative framework

An accurate history includes :

  • History of the presenting problem (character, severity and duration of symptoms)
  • Client concerns and beliefs regarding their problems
  • Past medical history, including use of alcohol, tobacco and other substances
  • Medicines being taken
  • Allergies
  • Family and community circumstances, including identifying environmental health factors that may contribute to client's health problems
  • Basic dietary information, including diet history to determine food and drink intake

Related health care providers may include :

  • Personnel internal to the service provider
  • External health care providers
  • Other service providers

Client information may include :

  • Significant ongoing health problems
  • Current medications
  • Clinical progress notes relevant to the presenting problem
  • Record of allergies
  • Family history
  • Medical and surgical history, including but not limited to:
  • pain
  • respiratory symptoms
  • urinary symptoms or abdominal symptoms
  • diseases such as diabetes, rheumatic fever or valvular heart disease
  • immunisation status
  • surgical history
  • use of alcohol and other drugs
  • oral health care history
  • Documents such as:
  • client file/notes
  • reports/results from referral, allied professionals and specialists (including x-ray, pathology tests)

Standing orders /written care protocols include :

  • Written guidelines or orders that support the clinical assessment and management of presenting health problems (eg. CARPA)

Medical equipment includes , but is not limited to :

  • Steriliser
  • Auroscope
  • Haemoglobinometer
  • Eye charts
  • Tape measure
  • Sphygmomanometer
  • Stethoscope
  • Ophthalmoscope
  • Glucometer
  • Scales
  • Thermometers (relevant types)
  • Urinalysis strips
  • Peak expiratory flow rate meters
  • Blood glucose testing units
  • Surgical instruments
  • Centrifuge
  • Plaster cutter
  • Nebulisers
  • Resuscitation equipment (including oxygen equipment)

Vital signs include :

  • Temperature
  • Pulse
  • Blood pressure
  • Respiratory rate

Non -clinical factors responsible for abnormal readings may include :

  • Failure to properly shake down a mercury thermometer
  • Effect of ingestion of hot or cold beverage on oral temperature measurement
  • Differences in temperature measurements taken at sites (ie. oral, axillary, ear)
  • Effect of exertion and anxiety on pulse rate and blood pressure
  • Impact of cuff size on the accurate measurement of blood pressure
  • Faulty equipment
  • Failure to correctly calibrate equipment
  • Impact of environmental factors on equipment

Health assessments may include :

  • Routine health assessments for clients with chronic disease
  • Well-person's health check
  • Assessment of client with presenting physical problems

Routine health assessments may be initiated for :

  • Clients with identified chronic disease, such as:
  • diabetes
  • chronic renal impairment
  • heart disease
  • joint disease
  • hypertension
  • asthma
  • Well-person's health check, appropriate to:
  • age
  • sex
  • ethnicity
  • regional disease prevalence

Observation of client includes :

  • Physical appearance
  • Body language and speech
  • General appearance (the 'unwell child')

Clinical tests may be initiated in response to :

  • Standard protocols for routine health checks
  • Results of other tests and/or observations
  • Request from client, another practitioner or specialist

Examination /testing of client includes :

  • Assessment for signs and symptoms of serious underlying causes of fever, including:
  • general appearance (the 'unwell child')
  • history of pain, respiratory symptoms, urinary symptoms or abdominal symptoms
  • history of diabetes, rheumatic fever or valvular heart disease
  • respiratory rate and pulse rate
  • urinalysis
  • examination of skin for infection
  • examination of ears and throat
  • Urine specimen collection using multi-reagent sticks and including:
  • mid-stream urine collection
  • first pass urine collection
  • paediatric bag collection
  • Use of capillary and venous blood glucose levels (BGL) [also referred to as blood sugar levels (BSL)] in diagnosis and monitoring control of clients with diabetes
  • Examination of extremities, including:
  • feet of people with diabetes are examined for protective sensation, ulcers, calluses, infections, nail condition and peripheral circulation
  • extremities of clients with Hansen's disease are examined for ulceration and infection
  • Peripheral circulation problems
  • Assessment of infant and child growth, including:
  • measure, document and plot weight and height
  • compare growth with major developmental milestones and identify potential delayed growth
  • identify possible causes of delayed growth
  • Identify symptoms of pregnancy and calculate expected date of delivery.
  • Identify:
  • abnormal post-natal conditions
  • common or serious neonatal conditions

continued  ...

Examination /testing of client includes :
(continued )

  • Test:
  • blood pressure
  • blood glucose level
  • haemoglobin level
  • urinalysis
  • Measure (monitor):
  • height, weight and head circumference using correct equipment
  • Examine/assess:
  • external eye and eyelid
  • ear
  • skin (for infection and other significant variations)
  • peak flow rate
  • Simple abdominal examination:
  • locate tenderness
  • simple tests for peritoneal inflammation
  • presence of abdominal masses
  • Simple peripheral nerve examinations, including:
  • testing extremities (hands, feet) for light touch and sharp sensation
  • visible wasting of hand muscles
  • grip strength and finger abduction
  • Basic oral health assessment, including:
  • visual inspection of oral cavity, teeth and gums
  • palpation of gums and jaw-line for tenderness
  • identification of common dental variations from normal
  • Clinical assessment of eye problems, including:
  • lid eversion
  • identification of the signs and symptoms of trachoma (in children and adults), using the WHO simplified trachoma grading system
  • retinal photography
  • use of fluorescein staining
  • Visual acuity testing, including:
  • Snellen or Bailey-Lovie chart
  • E-chart
  • counting fingers
  • light perception

continued  ...

Examination /testing of client includes :
(continued )

  • Respiratory assessments, including:
  • measurement of adult, child and infant respiratory rates
  • chest auscultation, measurement of peak expiratory flow rate (adult, child)
  • recognition of signs of respiratory distress;
  • spirometry; oximetry
  • Ear examinations, including:
  • use of otoscope to identify abnormal appearance of tympanic membrane and/or ear canal
  • audiometry
  • tympanometry
  • Examination of extremities for:
  • protective sensation
  • ulcers
  • calluses
  • infections
  • nail condition
  • peripheral circulation

Especially hands and feet of people with chronic conditions (eg. diabetes or Hansens' disease)

  • Screen for:
  • diabetes
  • proteinuria
  • urinary tract infection
  • hypertension

Specimen collection includes :

  • Urine (mid-stream, first pass urine and paediatric bag collection)
  • Blood
  • Sputum
  • Faeces
  • Swabs for culture and sensitivity and for pcr testing from wounds, skin and bodily orifices where appropriate (e.g. throat, ear and nasal swabs)
  • Tissue samples (for example skin scrapings for fungal infections)

Correct procedures for collection and handling of human pathology samples include :

  • Correct use of both sealed vacuum system and needle and syringe
  • Observance of universal precautions in collection and handling of specimens for pathology testing
  • Use of appropriate sample/specimen containers
  • Accurate labelling in line with organisation policies and procedures
  • Correct packaging, storage and transportation, in accordance with legislative and regulatory requirements for specific samples/specimens
  • Correct disposal of waste (including sharps)

Presence of health signs and symptoms to be identified and described include :

  • Common respiratory problems, including:
  • nasal discharge
  • sore throat
  • cough
  • breathlessness
  • haemoptysis (blood in sputum)
  • Genitourinary conditions, including:
  • dysuria (urinary tract infection [UTI], sexually transmitted infection [STI])
  • urinary frequency (UTI, prostatism, diabetes)
  • haematuria (UTI, kidney trauma, urinary stones, tumour)
  • symptoms of sexual assault
  • Gastro-intestinal and abdominal conditions, including:
  • indigestion and heartburn
  • diarrhoea and/or vomiting
  • constipation
  • acute abdominal pain
  • Signs of trauma, such as burns, assault
  • Common ear health conditions, including:
  • ear ache
  • discharging ear
  • deafness
  • foreign bodies or impacted wax in the ear canal
  • vertigo
  • bleeding from the ear

continued  ...

Presence of health signs and symptoms to be identified and described include :
(continued )

  • Common types of skin conditions, including:
  • impetigo
  • cellulitis
  • boils
  • scabies
  • fungal infections
  • Common dental problems, including:
  • tooth decay or abscess
  • bleeding gums
  • poor dental hygiene (dental plaque, halitosis, gum recession)
  • inability to chew food (toothache, malocclusion, tooth loss)
  • jaw problem
  • Common eye problems, including:
  • red eyes (conjunctivitis, injury)
  • discharging eyes (conjunctivitis)
  • itchy eyes (allergic conjunctivitis)
  • squint, cross eye, misalignment
  • pain on blinking
  • rapid visual deterioration
  • gradual visual deterioration
  • Peripheral circulation problems

Clinical features suggesting potentially serious health problems include :

  • The 'unwell child'
  • Features suggesting dehydration
  • Chest pain, productive cough, haemoptysis, breathlessness or fast breathing
  • Pelvic pain, pain passing urine or blood in the urine
  • Abdominal tenderness or unexplained abdominal pain
  • Fever among high risk persons (infants, elderly and clients with chronic disease, valvular heart disease or past rheumatic fever)
  • Fever with features that might indicate serious infection (eg. abdominal pain, urinary symptoms, headache, productive cough, skin infection)
  • Wounds or sores that are deep, extensive, on the face or on the extremities of clients with diabetes
  • Unexplained weight loss
  • Heavy vaginal bleeding
  • Bleeding or pain in pregnancy
  • Rash with fever as sign of meningitis or measles.
  • Joint pain (possibly moving from limb to limb) and/or swollen face and/or heart murmur and fever (or recent history of fever) as a sign of rheumatic heart fever
  • Headache, pain, fever, photophobia and/or neck stiffness as sign of meningitis or encephalitis
  • Rash, high pitched cry, fever, skin discolouration as signs of meningococcal disease

Potentially serious or complicated health conditions include 

  • Serious infections (pneumonia, blood poisoning, meningitis, endocarditis, kidney infection)
  • Cancers (lung, bowel, throat, breast, leukaemia)
  • Heart disease (heart attack, angina and heart failure)
  • Asthma and chronic obstructive lung disease
  • Sexually transmitted infections (gonorrhoea, chlamydia, syphilis, HIV/AIDS, warts, genital herpes, pubic lice)
  • Pregnancy complications (miscarriage, ectopic pregnancy, placental abruption)
  • Surgical causes of abdominal pain (appendicitis, pancreatitis, biliary colic, renal stones)
  • Stroke, spinal cord injury, intra-cerebral bleeding

Information to promote and maintain good health may include :

  • Summary of test results and readings
  • Information on links between heart disease and smoking, diet and physical activity
  • Information on management of uncomplicated gastrointestinal conditions, such as:
  • constipation (ie. eat more fibre, drink more water, appropriate use of laxatives)
  • gastroenteritis (ie. maintain fluid intake, eat according to appetite, continue breast-feeding, handwashing and infection control)
  • indigestion and heartburn (eg. trial of antacids, avoid late meals, identify other aggravating factors - alcohol, aspirin, anti-inflammatory medicines, smoking)
  • food handling and storage
  • Information on causes of health problems, such as:
  • ear problems (ie. infection and relationship to poverty and crowding; traumatic and noise-induced deafness)
  • skin infections (ie. crowding; poor access to water; high levels of scabies infestation)
  • Information on strategies to manage health problems, such as diabetes, including:
  • physical activity, healthy diet (low fat, low sugar, high fibre carbohydrates, high vegetables and fruits), weight loss and foot care (eg. appropriate footwear, regular foot self-care, ongoing review)
  • use of medicines
  • importance of regular health checks
  • Information on dental health, including:
  • link between dental health and diet
    (ie. consumption of simple sugars and developing dental caries; specific risks such as lolly-pops and baby bottle with sweet drinks or cow's milk; suckling on breast all night)
  • chart showing oral assessment findings and teeth development
  • good dental hygiene practices (regular brushing and use of dental floss)
  • importance of regular dental checks, especially for clients with rheumatic heart disease

Signs of respiratory distress include :

  • Raised respiratory rate
  • Raised pulse rate
  • Increased respiratory effort (use of accessory muscles, inspiratory in-drawing of soft tissues)
  • Inability to speak through breathlessness
  • Anxiety

Presentations of common sexually transmitted infections include :

  • Male urethral discharge and/or dysuria
  • Vaginal discharge
  • Female pelvic pain
  • Ulcerative genital disease
  • Genital lumps

Reasons for testing urine include :

  • Screening for urine infection
  • Screening for kidney disease
  • Assessment of possible renal trauma
  • Ante-natal care

Unit Sector(s)

Not Applicable

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