HLTAHCS003 Complete routine physical health assessments

Release: 1

HLTAHCS003 Complete routine physical health assessments

Modification History

Not applicable.

Application

This unit describes the performance outcomes, skills and knowledge required to complete health assessments of Aboriginal and/or Torres Strait Islander clients as part of a multidisciplinary health care team. It requires the ability to complete routine physical examinations and tests, and to assess client health. This unit covers the ability to evaluate short term and uncomplicated health conditions and also to recognise serious presentations that require further investigation.

Health assessments may be routinely scheduled at specific intervals, could be completed when a client presents with a specific health issue or as part of ongoing care for a diagnosed condition.

This unit is specific to Aboriginal and/or Torres Strait Islander people working as health workers and health practitioners. They work as part of a multidisciplinary primary health care team to provide primary health care services to Aboriginal and/or Torres Strait Islander clients.

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

No regulatory requirement for certification, occupational or business licensing is linked to this unit at the time of publication. For information about practitioner registration and accredited courses of study, contact the Aboriginal and Torres Strait Islander Health Practice Board of Australia (ATSIHPBA).

Pre-requisite Unit

Nil

Competency Field

Health Care and Support

Unit Sector

Aboriginal and/or Torres Strait Islander Health

Elements and Performance Criteria

ELEMENTS	PERFORMANCE CRITERIA
Elements describe the essential outcomes	Performance criteria describe the performance needed to demonstrate achievement of the element.
1. Obtain client information and determine scope of assessment.	1.1. Complete health assessments according to scope of practice and organisational standard treatment protocols. 1.2. Consult relevant health professionals and available documentation about client health. 1.3. Obtain client and family medical and social history and discuss specific presenting problems using culturally appropriate and safe communication. 1.4. Obtain client information about effectiveness of any current medications and treatments. 1.5. Explain organisational requirements for maintaining confidentiality of information and permissions for disclosure. 1.6. Accurately document client history according to organisational policies and procedures. 1.7. Determine specific examination and test requirements from information gathered.
2. Complete physical examination and tests.	2.1. Explain the reason and procedures for each examination to the client, confirm understanding and obtain informed consent. 2.2. Implement required infection control precautions according to examination and test requirements. 2.3. Use correct protocols to measure vital signs and identify any significant variation from normal reference range. 2.4. Conduct physical examination and tests based on observations and client’s presentation, and with respect for community values, beliefs and gender roles. 2.5. Accurately record details of all measurements, examinations and tests according to organisational policies and procedures.
3. Evaluate, present and confirm health assessment findings.	3.1. Evaluate examination and test results to identify signs and symptoms of common, uncomplicated health conditions. 3.2. Recognise from examinations and tests signs and symptoms of potentially serious health problems and trigger referral for further investigation. 3.3. Determine own interpretation of client’s current health status based on history, presenting problems, examination and test results. 3.4. Provide clear and accurate reports and consult with other health care team members to verify results and confirm client’s health status. 3.5. Report any confirmed notifiable diseases according to procedural and legal requirements and within scope of own responsibility. 3.6. Update client records with health assessment details according to organisational policies and procedures.
4. Discuss assessment outcomes with client and/or significant others.	4.1. Provide information about verified assessment results in plain language using culturally appropriate and safe communication. 4.2. Discuss options for treatments and other interventions. 4.3. Encourage client and/or significant others to question and clarify outcomes, and purpose of potential treatments and interventions. 4.4. Confirm understanding and document information provided in client records.

Foundation Skills

Foundation skills essential to performance in this unit, but not explicit in the performance criteria are listed here, along with a brief context statement.
SKILLS	DESCRIPTION
Reading skills to:	interpret detailed familiar organisational policies and procedures interpret sometimes complex and unfamiliar standard treatment protocols and client records involving medical terminology and abbreviations.
Writing skills to:	use fundamental sentence structure, health terminology and abbreviations to complete forms and reports that require factual information.
Oral communication skills to:	ask open and closed probe questions and actively listen to elicit information from clients and determine understanding of information provided.
Numeracy skills to:	interpret sometimes complex medical numerical data and abbreviations in standard treatment protocols and client records take and record accurate measurements involving weights, lengths, rates and degrees complete calculations involving, percentages and ratios document medical numerical abbreviations in client records.
Planning and organising skills to:	determine a structured approach for health assessments and complete physical examinations and tests in a logical, time efficient sequence.
Technology skills to:	select and use medical equipment suited to purpose of physical examination and client characteristics.

Unit Mapping Information

This unit supersedes and is not equivalent to HLTAHW007 Undertake basic health assessments.

Links

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