Assessment Requirements for HLTAHCS003 Complete routine physical health assessments

Release: 1

Assessment Requirements for HLTAHCS003 Complete routine physical health assessments

Modification History

Not applicable.

Performance Evidence

Evidence of the ability to complete tasks outlined in elements and performance criteria of this unit in the context of the job role, and:

complete a physical health assessment of a total of five Aboriginal and/or Torres Strait Islander clients to collectively include:

females

males

people across the lifespan including children and adolescents through to the elderly

for each of the five clients, complete a head to toe physical examination and tests:

measurement of height, weight and waist circumference and calculation of body mass index

measurement of temperature

measurement of blood pressure, pulse rate and rhythm

measurement of respiratory rate and peak flow

examination of:

eyes, including physical examination and vision test

ears and hearing, including otoscopy

mouth, throat, teeth and gums

skin

hands and feet including observations for infective and fungal issues, oedema, abnormalities in the structure and shape, and nerve damage

chest by visual and aural observation of respiration for any signs of congestion and distress

abdomen by visual observation

urinalysis via dipstick testing

blood glucose test with a blood glucose testing meter

examinations for specific presenting problems

for each of the five clients:

evaluate all assessment information and report own interpretation of client’s current health status to health care team

consult with the health care team to verify assessment results and confirm client’s health status

discuss assessment outcomes with the client

document, in client’s records, accurate details of:

medical and social history

observations, examinations and tests completed

evaluation notes about the health of each client

information and referrals provided to the client

from assessments personally completed or from case study assessment documentation:

identify signs, symptoms and implications of four different potentially serious health problems, and report on and refer

identify one notifiable disease and implement procedures to notify.

Knowledge Evidence

Demonstrated knowledge required to complete the tasks outlined in elements and performance criteria of this unit:

organisational policies and procedures for:

maintaining client confidentiality

documenting health assessments

local state or territory legal requirements, and associated organisational procedures for reporting notifiable communicable diseases

organisational responsibilities and role boundaries of those involved in health assessments:

Aboriginal and/or Torres Strait Islander health workers and practitioners

medical practitioners, registered nurses and other members of the multidisciplinary care team

the role of standard treatment protocols in health assessments:

types that are used by primary health care organisations including Standard Treatment Manuals (STM) and how to access

purpose, format and inclusions

how to use to identify physical health assessment requirements

key information collected and recorded in medical and social histories for health assessments and how this may differ according to the age of the client

key elements of routine physical health assessments and how types of examinations and tests may differ according to the age of the client and their presentations

different types of infection control precautions and when these would be used for different types of physical examinations and tests

equipment and procedures for health examinations and tests, and ‘normal’ reference range for adults:

height, weight, waist circumference and body mass index

temperature

blood pressure, pulse rate and rhythm

respiratory and peak flow rate

examination of:

eyes, including physical examination and vision test

ears and hearing, including otoscopy

mouth, throat, teeth and gums

skin

hands and feet including observations for infective and fungal issues, oedema, abnormalities in the structure and shape, and nerve damage

chest including visual and aural observation of respiration for any signs of congestion or distress

abdomen including visual observation

urinalysis via dipstick testing

blood glucose test with a blood glucose testing meter

understanding of anatomy and physiology sufficient to identify major body systems, associated organs and their overall functions:

circulatory system

digestive system

endocrine system

immune system

integumentary system

musculoskeletal system

nervous system

reproductive system for females and males

respiratory system

urinary system

common short term and uncomplicated health conditions (those that would generally respond to a course of treatment or ongoing self-care), common presenting signs and symptoms and required examinations:

respiratory tract infections

eye, ear and mouth infections

bacterial, viral, fungal and parasitic skin infections

digestive and gastrointestinal conditions including gastroenteritis

urinary tract infections

for chronic and communicable diseases of high incidence in Aboriginal and/or Torres Strait Islander populations, the major risk factors, signs and symptoms that would trigger referral for investigation:

cardiovascular disease

chronic respiratory disease, including asthma and obstructive lung disease

chronic kidney disease

chronic liver disease

cancer

diabetes

musculoskeletal conditions, including arthritis

eye, ear and oral disease

sexually transmitted infections (STIs)

blood borne viruses including HIV, hepatitis A, hepatitis B and hepatitis C

communicable diseases of current significance in the local state, territory or local community.

Assessment Conditions

Skills must be demonstrated in a health service workplace within a multidisciplinary primary health care team.

Evidence of performance must be gathered:

during on-the-job assessments in the workplace under live conditions while interacting with Aboriginal and/or Torres Strait Islander people, or

during off-the-job assessments in the workplace, not under live conditions, using simulated activities while interacting with Aboriginal and/or Torres Strait Islander people.

Evidence of workplace performance can be gathered and reported through third party report processes. (Refer to the Companion Volume Implementation Guide for information on third party reporting.)

Evidence can be supplemented by assessments in a simulated workplace environment using simulated activities, scenarios or case studies only when:

the full range of situations covered by the unit cannot be provided in the individual’s workplace, or

situations covered by the unit occur only rarely in the individual’s workplace.

Assessment must ensure the use of:

personal protective equipment for infection control

medical equipment and consumables used for health assessments

clinical waste and sharps disposal bins

client records

template forms or reports for documenting client histories, assessment details and results

health assessment standard treatment protocols used by the organisation, which can include Standard Treatment Manuals

organisational procedures for:

maintaining client confidentiality

documenting health assessments

reporting notifiable communicable diseases.

Assessors must satisfy the Standards for Registered Training Organisations requirements for assessors, and:

be an Aboriginal and/or Torres Strait Islander person who has applied the skills and knowledge covered in this unit of competency through experience working as an Aboriginal and/or Torres Strait Islander health worker or practitioner, or

be a registered health practitioner with experience relevant to this unit of competency and be accompanied by, or have assessments validated by, an Aboriginal and/or Torres Strait Islander person.

Links

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