HLTHOM604C Perform clinical screening examination and assessment

Release: 1

HLTHOM604C Perform clinical screening examination and assessment

Modification History

Not Applicable

Unit Descriptor

Descriptor	This unit of competency describes the skills and knowledge required to perform screening examination of vital signs and physical condition and to make a screening assessment of the client Procedures are governed by the application of local legislation

Application of the Unit

Application	This unit applies to work in homœopathy

Licensing/Regulatory Information

Not Applicable

Pre-Requisites

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

ELEMENT	PERFORMANCE CRITERIA
1. Observe client's vital signs	1.1 Observe client's demeanour and appearance 1.2 Organise examination 1.3 Communicate examination procedures to client 1.4 Undertake examination for vital signs
2. Conduct screening physical examination according to local legislative guidelines	2.1 Conduct screening examination when needed to ensure client safety and elicit signs of disease 2.2 Identify areas of investigation 2.3 Organise examination 2.4 Communicate examination procedures to client 2.5 Conduct examination using appropriate techniques, equipment and supplies 2.6 Conduct examination according to clinic guidelines, local regulation and legislative requirements
3. Make a screening assessment and refer for further examination	3.1 Conduct extended interview 3.2 Make a screening assessment to ensure client safety 3.3 Determine the need for referral for extended physical examination and/or further diagnostic procedures 3.4 Arrange referral as needed
4. Monitor and record findings	4.1 Record all findings and file in accordance with clinic guidelines 4.2 Monitor outcomes of referrals 4.3 Treat all documentation confidentially
5. Discuss outcomes of referral with the client	5.1 Discuss rationale of the medical diagnosis/prognosis with the client 5.2 Respond to client enquiries using language the client understands 5.3 Discuss referral and collaborative options with the client if necessary

Required Skills and Knowledge

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: Anatomy and physiology relevant to evaluating results of the screening assessment Basic nutritional requirements for the various ages and stages of life Clinic and local legislative guidelines relevant to assessment techniques Clinical anatomy and physiology relevant to performing the examination Disease processes and affecting factors for a range of common diseases Ethical and legal implications of enquiry and examination Further testing procedures Homœopathic tools and resources Interview techniques Normal anatomy in relation to diagnostic imaging procedures Pathophysiology and disease process and classification relevant to making a screening assessment and interpreting the findings Pathophysiology and disease process relevant to performing the examination Referral procedure and recommended referral options Relevant anatomy and pathophysiology to competently collect specimens and interpret results Relevant medical equipment Terminology correct to discipline The environmental causes of disease The mode of presentation of potentially fatal and emergency medical and surgical conditions The practitioner's own limitations in clinical diagnosis and therapy sufficient to safeguard the client The purpose, method and sequencing of screening physical examinations The relationship between physical findings, clinical diagnosis and homœopathic prescribing The relationship between physical findings, clinical diagnosis and homœopathic prescribing The relationship between physical findings, diagnosis and homœopathic prescribing
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: Accurately record information Accurately record information in a systematic manner in accordance with clinic guidelines Address time management requirements during consultation Communicate effectively to gain required information Correctly dispose of waste and sharps in accordance with workplace policy Correctly monitor, clean and maintain equipment Demonstrate communication skills Discuss and observe treatment protocols Identify and record signs and symptoms of disease Identify clinical signs of nutritional imbalance Interpret and understand the significance of findings Interpret medical test data such as urine, blood test data, faecal and biopsy reports Obtain problem focused information by performing inspection, palpation, auscultation, percussion and appropriate manoeuvres Read and interpret medical reports Read and interpret medical test results or documents Recognise when specimen collection is required Relate results of the test to homœopathic symptomatology Take into account opportunities to address waste minimisation, environmental responsibility and sustainable practice issues Use homœopathic tools and resources Use medical reference texts including homœopathic and western medicine texts Use terminology correct to discipline Use, monitor and maintain appropriate medical equipment

Evidence Guide

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 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 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:	An appropriately stocked and equipped clinic or simulated clinic environment Reference texts Local legal guidelines Appropriate assessment environment Skilled assessors
Method of assessment	Observation in the work place Written assignments/projects or questioning should be used to assess knowledge Case study and scenario as a basis for discussion of issues and strategies to contribute to best practice Examples of assessment notes Clinical skills involving direct client care are to be assessed initially in a simulated clinical setting (laboratory). If successful, a second assessment is to be conducted during workplace application under direct supervision
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 HLTHIR301B Communicate and work effectively in health HLTHOM601C Apply homœopathic diagnostic framework HLTIN301C Comply with infection control policies and procedures

Range Statement

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.
Examination is organised means:	Consent is obtained from a parent/ guardian/ caregiver prior to commencing a physical examination of a minor or an adult under guardianship Equipment is arranged Equipment is checked/calibrated so that it is in good working order Client and examiner are positioned Examination is sequenced for efficiency and client and examiner comfort
Procedures are communicated may include:	Informing client of procedures to be carried out Obtaining client consent at each stage of examination An appropriate adult (parent/guardian/caregiver) must be present during examination of a minor or an adult under guardianship
Examination for vital signs must include competency in:	Measuring blood pressure, respiration and pulse rates, and temperature Performing standardised sequence of examination Using required equipment, including sphygmomanometer stethoscope timing device thermometer peak flow meter and disposable mouth pieces, if required Following standardised procedures for infection control
Areas of investigation may include:	Full screening examination General appearance and vital signs Skin Head, eyes, ears, nose, oral cavity and throat Neck Breasts and axillae Thorax and lungs Heart and great vessels Abdomen Limbs Neurological system Lower back Cardiovascular system Reproductive system Respiratory system Gastrointestinal system Urinary system Endocrine system
Techniques include:	Inspection Palpation Auscultation Percussion Appropriate manoeuvres
Equipment must include:	Thermometer Sphygmomanometer Stethoscope Timing device Peak flow meter and disposable mouth pieces Examination table Otoscope Penlight Percussion (reflex) hammer Measuring tape Equipment for measuring height and weight Goose-neck lamp or other light source And may include: Ophthalmoscope Tuning fork(s) Nasal speculum Skin marking pencil Glucometer and disposable lancets devices
Supplies required must include:	Half-sheet for draping Examination gowns Disposable gloves Tongue depressors Cotton-tipped swab Gauze squares Medi alcohol swabs Hazard bags for infection control Sharps containers Instrument cleaning supplies And may include: Visual acuity charts Goggles/protective eyewear
Extended interview may include:	Extended history taking Formulating clinical diagnostic hypothesis Data gathering and hypothesis testing Identifying role of past medical history Identifying role of client profile Relating signs and symptoms to diagnostic areas using a standard system of clinical evaluation
Screening assessment must imply one of the following:	The need for further examination or investigation The need for further evaluation of the signs and symptoms to establish a clinical diagnosis A definite clinical diagnosis A dangerous pathology or psychiatric condition A condition which can be safely and satisfactorily managed by the practitioner
Screening assessment involves:	Establishing expected normal course of disease including: natural duration of disease progress, extension, radiation and pace probability of remission
The need for referral may include:	Suspected dangerous pathology Unknown symptom complex or condition Signs of notifiable disease Need for medical diagnostic information
Further diagnostic procedures may include:	Diagnostic laboratory tests Diagnostic imaging Referral to a diagnostician
Outcomes of referrals includes:	Ascertaining that diagnostic procedures or extended examination has been carried out by the appropriate practitioner Assessing and analysing the data arising out of the referral

Unit Sector(s)

Not Applicable