Elements and Performance Criteria
- Determine the scope of the assessment and client needs
- Establish client's purpose for consultation and identify the symptoms experienced
- Determine client's eligibility for service using clinic/personal policies
- Explain services able to be provided and limits of available services
- Explore and clarify client's expectation of the service/clinic
- Identify factors likely to have a negative impact on assessment in consultation with the client and implement strategies to minimise the effects of these factors wherever possible
- Define personal abilities, level of professional competence and parameters of role to the client
- Refer client to other health care providers where their needs are identified as beyond the scope of the services able to be provided, or if in the opinion of the practitioner their needs are best met by doing so
- Identify and promote legal rights of the client
- Obtain and record an accurate history of the client
- Seek client history from the client in a respectful way with all enquiries asked in a purposeful, systematic and diplomatic manner
- Collect and record accurate, relevant and well organised information in a manner which can be interpreted readily by other professionals
- Ensure information is treated and stored in a confidential manner
- Manage the health assessment
- Obtain informed client consent prior to conducting tests in accordance with legislative requirements
- Investigate abnormal findings in a deliberate, logical and appropriate manner
- Assess the reliability of data obtained and establish, where possible, appropriate clinical correlation with client's presenting condition
- Use questions to clarify results and gain further information in a manner relevant to client needs and test results
- Determine need to carry out laboratory tests based on the integration of previously obtained clinical data and history
- Adhere to agency protocol required in ordering tests
- Allow adequate time during consultation to gather critical information
- Identify and minimise factors that may interfere with the information gathering process
- Identify, establish and maintain essential requirements for the maintenance of clinical and practitioner hygiene
- Anticipate any potential sensitivities of the client and adapt approach to take these into account, while ensuring the maintenance of client dignity
- Make a comprehensive assessment of the client
- Observe and identify signs of disease/condition according to nutritional medicine framework
- Seek specific details of signs and symptoms of the presenting complaint/s or health conditions
- Employ other assessment techniques as appropriate
- Record, accurately, all information in a systematic manner in accordance with clinic guidelines