Unit of competency details

Descriptor 

This unit of competency describes the skills and knowledge required to observe the condition of the client and gather information relevant to the case, according to western herbal medicine framework

Application 

This unit applies to work in western herbal medicine

Employability Skills 

This unit contains Employability Skills

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.

ELEMENT 

PERFORMANCE CRITERIA 

1. Determine the scope of the assessment and client needs

1.1 Establish the client's purpose for consultation and identify the symptoms experienced

1.2 Determine client's eligibility for service using clinic/personal policies

1.3 Clearly explain services able to be provided and limits of available services

1.4 Explore and clarify client's expectation of the service/clinic

1.5 Identify factors likely to have a negative impact on assessment  in consultation with the client and implement strategies to minimise the effects of these factors wherever possible

1.6 Define to the client, personal abilities, level of professional competence and parameters that determine practice at all times

1.7 Refer client to other health care providers  where their needs are identified as beyond the scope of the services able to be provided, or if in the opinion of the practitioner their needs are best met by doing so

1.8 Identify and promote legal rights of the client

2. Obtain and record an accurate history of the client 

2.1 Seek information required from the client for the history in respectful way with all enquiries asked in a purposeful, systematic and diplomatic manner

2.2 Collect and record accurate, relevant and well organised information in a form which can be interpreted readily by other professionals

2.3 Treat information as confidential and store securely

3. Manage the health assessment

3.1 Obtain informed client consent prior to conducting tests in accordance with legislative requirements

3.2 Pursue and investigate abnormal findings in a deliberate, logical and appropriate manner

3.3 Assess reliability of data obtained and establish appropriate clinical correlation with client complaints where possible

3.4 Use questions to clarify results and gain further information in a manner relevant to client needs and test results

3.5 Base any decision to carry out laboratory on the integration of previously obtained clinical data and history

3.6 Adhere to protocols required by the agency in ordering tests

3.7 Allow adequate time during consultation to gather critical information

3.8 Identify and minimise factors that may interfere with the information gathering process

3.9 Identify, establish and routinely observe essential requirements for the maintenance of clinical and practitioner hygiene

3.10 Anticipate potential sensitivities  of the client, adapt approach accordingly to take these into account, and take steps to ensure client dignity is maintained at all times

3.11 Respond appropriately to client feedback and complaints

4. Make a comprehensive assessment of the client

4.1 Identify signs of disease /condition  and further observations according to herbal medicine framework

4.2 Elicit specific details of signs and symptoms of the presenting complaint/s

4.3 Use other appropriate assessment techniques 

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

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:

• Anatomical terminology and levels of organisation
• Anatomy and physiology according to various stages of life
• Biochemistry
• Clinical features and pathophysiology of common bacterial and viral diseases to assess, stage, severity and likely prognosis
• Critical information required for diagnosis and treatment according to herbal medicine framework
• Ethical and legal implications of enquiry
• Factors affecting transmission of disease and choice of treatments of common infectious diseases
• Knowledge and understanding of:

• anatomical systems including muscoskeletal - including muscles, bones, cartilage, joints, head, upper trunk, upper limb, pelvis, lower limb
• cardiovascular including haemopoetic - including vascular system, spleen, heart and pericardium, systemic arteries, systemic veins, portal veins, foetal circulation
• ENT and special senses - including hearing and equilibration, vision, smell, taste
• gastrointestinal - including mouth, salivary glands, tongue, pharynx, oesophagus, abdomen and peritoneum, stomach, small intestine, large intestine, liver, biliary system, pancreas
• lymphatic - including thoracic viscera, abdominal and pelvic viscera, alimentary tract, urinary and genital systems, trunk and limbs, deep and superficial lymph nodes
• nervous - including peripheral, autonomic and central nervous systems
• respiratory - including larynx, trachea, lungs and mediastinum, pleura
• urogenital (reproductive and urinary) and endocrine - including kidneys, ureter and bladder, male genital organs, female genital organs, thyroid, parathyroid glands, pituitary gland, adrenal gland, thymus gland

• Identification of infectious organism, indications, complications, epidemiology, occurrence, mode of transmission, vectors, incubation period, period of communicability, presentation, diagnosis, treatment, management and prevention
• Pathophysiology and disease processes
• Pathophysiology and disease processes of common clinical diseases and interactivity between them, to the level necessary to support the making of a screening assessment and assessment of the client's condition to support the practice of natural/traditional medicine

continued  ...

Essential knowledge  (contd ):

• Pathophysiology and disease processes affecting the nervous system

• central and peripheral nervous tissue, brain, spinal cord and associated nerves, sensory, motor and integrative systems, autonomic nervous system
• endocrine system - thyroid, parathyroid and adrenal glands, pancreas, calcium and bone metabolism, pituitary gland, pineal gland
• ENT and special senses - vision, hearing, smell, taste
• respiratory system - pulmonary function, gas transport, regulation of respiration, respiratory adjustments
• cardiovascular system - blood, clotting, erythropoietin, cardiac cycle
• lymphatic system - immunity, allergy
• urogenital system - renal function, fluid balance, male and female reproductive systems, musculoskeletal system - processes affecting joints, muscles, tendons, ligaments and bones

• Physiology including:

• basic physiology - including physiology of muskoskeletal system - muscles, posture and movement; nervous system - central, peripheral and automatic nervous systems
• cardiovascular system - heart, circulation
• ENT and other senses - hearing and equilibration, vision, smell, taste
• gastrointestinal - motility, secretions, movement of food, digestion and absorption
• general physiology - including cell structure and function, metabolism, levels of organisation in the body
• lymphatic system - lymph, immunity and allergy
• respiratory system - pulmonary function
• urogenital and endocrine - renal function, micturition, extracellular fluid, metabolism, thyroid gland, hormones, and reproduction

• Philosophical approach to diagnosis and treatment
• Physical signs and symptoms of disease
• Relevant testing and assessment options and procedures
• Symptomology and pathology according to herbal medicine practice
• Terminology correct to discipline
• The cost benefit ratio of special tests or studies
• The legal and ethical requirements for confidentiality
• The minimum number of required additional tests to request
• Time management requirements during consultation

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:

• Access and interpret up-to-date information
• Apply legal and ethical requirements for confidentiality
• Apply methods of keeping medical records
• Apply time management requirements during consultation
• Communicate effectively to gain required information
• Conduct external physical examination
• Demonstrate communication skills
• Demonstrate observation skills
• Demonstrate physical examination procedures
• Demonstrate record keeping skills
• Demonstrate respect for practitioner/client boundaries
• Detect and record symptoms and signs present including precipitating factors, relieving factors and associated manifestations
• Identify location, stage and characteristics of disease
• Request high precision laboratory and/or radiology tests when required
• Understand and discuss medical reports
• Use a range of medical equipment used in external physical examinations
• Use equipment and technology competently and safely
• Use terminology correct to discipline

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 a range of workplace situations
• Assessment may contain both theoretical and practical components and examples covering a range of clinical situations
• Evidence is required of both knowledge and skills application
• 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 :

• Assessment should replicate workplace conditions as far as possible
• Simulations may be used to represent workplace conditions as closely as possible
• Where, for reasons of safety, access to equipment and resources and space, assessment takes place away from the workplace, simulations should be used to represent workplace conditions as closely as possible
• Resources essential for assessment include:

• an appropriately stocked and equipped clinic or simulated clinic environment
• skilled assessors
• relevant assessment instruments
• appropriate assessment environment

Method of assessment 

• Observation of performance
• Examples of assessment notes
• Simulated assignments
• Written or verbal short answer tests
• Practical demonstrations and exercises
• Research work or written reports of observations in a practical setting
• Oral questioning on technique or assessment strategy
• Case studies and scenarios as a basis for discussion of issues and strategies to contribute to best practice in the work environment

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
• HLTIN301C Comply with infection control policies and procedures

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.

Factors likely to have a negative impact on assessment may include :

• Language difficulties
• Disabilities
• Emotional trauma
• Lack of privacy or focus due to other parties being present
• Cultural or gender factors

Other health care professional may include :

• Doctors
• Social workers
• Alternative and complementary health practitioners
• Counsellors
• Podiatrists, physiotherapists

Client history may include :

• Date of presentation
• Identifying personal details
• Source of referral (if applicable)
• Main presenting complaint or reason for consultation
• Presenting symptom picture
• General state of health

• physical
• emotional
• allergies
• dietary picture
• sleep pattern
• exercise
• leisure activities

• Childhood and adult illness
• Accidents, injuries, operations
• Hospitalisations
• Occupational history and environment
• Other current medical treatment
• Medication, supplements and natural remedies - current and previous
• Social lifestyle including social drug use
• Family history

Potential sensitivities may include :

• Gender
• Ethnicity
• Language
• Religious beliefs
• Cultural heritage
• Sexuality
• Ability
• Presenting disease state and personal history

Signs of disease /condition may refer to :

• Precipitating factors
• Relieving factors
• Associated manifestations
• Indications of stage and status of illness
• Symptom qualities
• Functional and pathological disturbances

Other appropriate assessment techniques may include :

• Observation
• Discussion
• Taking temperature
• Taking pulse and blood pressure
• Palpation and auscultation
• Percussion
• External physical examination
• Iridology techniques
• Skin examination
• Urine tests
• Assessment of growth (height, weight, head circumference) and development
• Overview of system by enquiring about the presence of previously diagnosed organic diseases and functional disorders
• Any other method in which the practitioner has been trained to a competent standard

Legislative requirement :

• All procedures must be conducted according to legislative and regulatory requirements