Elements and Performance Criteria
- Elements define the essential outcomes of a unit of competency.
- Propose care plan
- Access health assessment outcomes according to organisational procedures and policies
- Identify specific aspects of health assessment to address in health care plan
- Propose treatment as part of the care plan in accordance with policies and procedures
- Develop the plan with primary health care team, using relevant standing orders and written care protocols
- Clearly establish responsibilities for implementing the care plan
- Document proposed health care plan in client’s file in line with organisational policies and procedures
- Communicate proposed health care plan to client
- Use effective and culturally appropriate and safe communication skills to discuss the proposed care plan with clients and explain how it relates to their health assessment results
- Provide client with information about each aspect of the proposed care plan and the rationale for its inclusion
- Encourage the client to ask questions about the proposed care plan to support understanding and cooperation, and agreement
- Explain self-management aspects of the proposed care plan
- Consult with the primary health care team about any client-suggested changes to the proposed plan and adjust plan as appropriate
- Document finalised plan according to organisational procedures and policies
- Implement care plan
- Refer clients as required to relevant health professionals in line with community, organisational and regulatory requirements
- Conduct treatment in accordance with the care plan
- Support client to take a self-care approach to implementation in line with individual, organisational and community requirements
- Maintain current, complete, accurate and relevant records for each client contact
- Provide information on healthy nutrition and lifestyle choices as part of the care plan
- Provide accurate information regarding nutrition and lifestyle choices, and the impact of poor nutrition and lifestyle choices, including alcohol and smoking
- Discuss risk factors relating to specific nutrition and lifestyle choices for the individual client in the context of their family, culture and local community
- Provide information on early intervention and prevention practices to avoid disease caused by poor nutrition and lifestyle choices
- Assist client to select an appropriate and varied diet in line with dietary guidelines and client needs
- Develop strategies to assist individuals who have not exercised for some time to become more active
- Offer brief interventions for smoking cessation
- Establish patterns of alcohol consumption and offer brief interventions
- Make appropriate referrals where required
- Provide care and support for clients with chronic condition as part of the care plan
- Provide information about the nature, incidence and potential impacts of chronic conditions in specific relation to the client’s own health
- Provide information on practices to manage chronic conditions to address identified individual needs
- Provide practical advice relating to maintaining good health in relation to prevalent chronic conditions and in line with community needs and organisational guidelines
- Explain and/or demonstrate practices for early detection of specific chronic conditions in line with organisational guidelines
- Support clients to take a self-care approach to maintaining health
- Make appropriate referrals for clients with chronic conditions in line with organisational guidelines
- Monitor health care
- Encourage clients and family/carer to maintain health by being actively involved in the care plan
- Monitor client health in line with individual schedule and criteria incorporated in care plan
- Reassess and review care plan as required where client fails to progress, in accordance with expectation
- Ensure standing order/written care protocols underpin health assessment and management actions
- Conduct health monitoring in accordance with organisational policies and procedures and occupational health and safety requirements
- Organise follow-up care for clients with chronic conditions using computer and/or paper-based registers
- Identify when clients are overdue for health care checks and employ active-recall strategies
- Review effectiveness of health care
- Gain feedback from the client and/or family or carer/s about their level of comfort and compliance with the health management regime
- Determine degree of improvement of client’s condition and compare with expectations outlined in health care plan
- Provide client and/or family/carers with clear information about their level of improvement in relation to the health care plan and their level of compliance
- Evaluate impact of ongoing health management in relation to the client’s physical, mental and emotional condition and behaviour, in consultation with the primary health care team