Elements and Performance Criteria
- Assess client's health
- Undertake detailed assessment in line with protocols for specific health condition(s)
- Review client records to determine priorities and potential areas of risk for each client
- Evaluate impact of previous care strategies
- Initiate relevant examinations and tests as required to identify and/or clarify any identified or suspected health issues and/or abnormalities
- Question client appropriately in relation to any health issues and/or abnormalities and to inform ongoing health management
- Interpret common pathology tests
- Develop care plan
- Formulate care plan to address identified health issues
- Develop care plan in collaboration with the client
- Develop care plan with reference to the relevant health care team and other health care providers
- Propose treatment in accordance with organisation policies and procedures and as negotiated with the client, their family and/or the community
- Include measures consistent with standing orders/written protocols, based on health assessment findings
- Refer clients as required to relevant health professionals in line with community, organisation and regulatory requirements
- Document health care plan in the client's file in accordance with organisation policies and procedures
- Implement care plan
- Build and maintain relationship of trust with each client, with active promotion of and strict adherence to confidentiality
- Provide care (treatment) to address identified health issues and manage chronic health problems
- Encourage client to undertake regular health reviews to address identified health issues
- Encourage client to maintain identified care practices to address identified health issues
- Monitor client health regularly to assess impact of treatment(s) and care services
- Provide client with information relevant to promoting and maintaining their health in a way they understand
- Provide client with information about each aspect of the care plan and the rationale for its inclusion
- Initiate action (including referral) as determined by effective decision-making in line with organisation policies based on results of clinical assessment and in accordance with accepted procedures and protocols
- Conduct treatment in accordance with the care plan, organisation policies and procedures and occupational health and safety requirements
- Use medical equipment correctly and maintain in accordance with manufacturer's specifications and organisation policies
- Maintain current, complete, accurate and relevant records for each client contact
- Review care plan