Assessment Requirements for HLTAHCS004 Complete comprehensive physical health assessments

Release: 1

Assessment Requirements for HLTAHCS004 Complete comprehensive 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 comprehensive 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

people presenting with:

complex acute conditions

chronic disease

communicable disease

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

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 lung function including respiratory and peak flow rate and spirometry breathing test

examination of:

eyes, including physical examination and vision test

ears and hearing, including otoscopy

mouth, throat, teeth and gums

skin and any wounds present

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 or distress

abdomen by visual observation and palpation

urinalysis via dipstick and pathology testing

blood glucose test with a blood glucose testing meter

examinations for specific presenting problems

for each of the five clients:

determine requirements for specific pathology tests according their individual presentations

collect and process blood samples for pathology testing

process swabs (collected by self or client) for pathology testing

evaluate the results of pathology tests

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 of emerging comorbidity for two clients with existing chronic disease

identify signs of the following conditions or diseases:

cardiovascular disease

acute or chronic respiratory disease, including asthma

kidney disease

liver disease

cancer

diabetes

musculoskeletal conditions, including arthritis

eye, ear and oral disease

communicable disease

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 comprehensive, complex health assessments:

Aboriginal and/or Torres Strait Islander health 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 for clients with complex needs

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 comprehensive physical health assessments and how types of examinations and tests may differ according to the age of the client and their presentation

the meaning of primary and secondary survey in health assessments

the value of an opportunistic approach to chronic and communicable disease surveillance including completing comprehensive health assessments and tests as people come to the clinic for any reason

different types of infection control precautions and when these would be used for different types of physical examinations and collection of specimens for pathology testing

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

height, weight, waist circumference and body mass index

temperature

blood pressure, pulse rate and rhythm

lung function including respiratory and peak flow rate, and spirometry tests

examination of:

eyes, including physical examination and vision test

ears and hearing, including otoscopy

mouth, throat, teeth and gums

skin and wounds

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 and distress

abdomen including visual observation and palpation

urinalysis via dipstick testing

blood glucose test with a blood glucose testing meter

pathology tests and where to locate information in Standard Treatment Manuals:

full blood examination

erythrocyte sedimentation rate (ESR)

random and fasting blood glucose

haemoglobin and glycated haemoglobin

blood ketones

electrolytes and creatinine

liver function

lipid profile

thyroid function

iron studies

cardiac enzymes

urinary albumin-creatinine ratio

urine microscopy, culture and sensitivity

microscopy, culture and sensitivities for infections via body fluid and swab collection

for each of the above listed pathology tests:

indications including what signs and symptoms may trigger tests; what diseases or conditions are diagnosed and monitored using these tests

correct methods of collection, storage and transport of specimens, and requirements for documentation

‘normal’ range of test values

the significance of results that vary significantly from the normal range and what types of conditions and diseases abnormal results may indicate

typical inclusions of pathology request forms, and the importance of accuracy when completing

understanding of anatomy and physiology sufficient to identify major body systems, associated organs and their 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 acute conditions associated with major body systems and organs and common presenting signs and symptoms, and required examinations

features of chronic disease:

complex causality

multiple risk factors, including genetic and lifestyle

long latency periods

a prolonged course of illness

functional impairment or disability

lifestyle risk factors that can contribute to, exacerbate and progress all types of chronic disease:

smoking

physical inactivity

unhealthy nutrition and body weight

consumption of alcohol at unsafe levels

use of illicit drugs

unsafe sexual practices

chronic and communicable diseases of high incidence in Aboriginal and/or Torres Strait Islander populations:

cardiovascular disease including coronary heart disease, heart failure, cardiomyopathy, rheumatic heart disease, atherosclerosis, peripheral vascular disease and cerebrovascular disease

chronic respiratory disease, including Asthma and obstructive lung disease

chronic kidney disease and end stage renal failure

chronic liver disease including alcoholic liver disease and cirrhosis

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

for each of the above listed chronic and communicable diseases of high incidence in Aboriginal and/or Torres Strait Islander populations:

the major signs and symptoms

blood and other tests used to diagnose and monitor

basic pathophysiology sufficient to understand the impact and functional changes on relevant body organs and systems

the concept of comorbidity and overview of the main linkages between diseases sufficient to understand that signs and symptoms may indicate the presence of multiple diseases

for cardiovascular disease:

the concept of ‘cardiovascular risk factors’

the significance of an individual having multiple risk factors

the concept of ‘high absolute risk’

for chronic kidney disease:

the importance of early stage detection in deferring or preventing end-stage kidney disease (renal failure)

for diabetes:

main elements of the diabetes annual cycle of care

causes, signs and symptoms of diabetic foot disease

screening tools and procedures that can be used to assess diabetic foot disease.

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

specimen collection documents

pathology results

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 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