Elements and Performance Criteria
- Determine the scope of the assessment and the client's 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 clearly
- Explore and clarify client's expectation of the service/clinic
- Define personal abilities, level of professional competence and parameters of role to the client and determine practice at all times
- Identify factors likely to have a negative impact on assessment in consultation with the client and strategies implemented to minimise the effects of these factors wherever possible
- Refer client to other health care professionals where the needs of the client are identified as beyond the scope of the services able to be provided, or if in the opinion of the practitioner the needs of the client are best met by doing so
- Identify and promote the legal rights of the client
- Obtain and record an accurate history of the client
- Seek information required from the client for the client's history 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 form which can be interpreted readily by other professionals
- Manage information in a confidential and secure way
- Prepare the client for assessment
- Perform an assessment of the client
- Obtain informed client consent prior to conducting assessment, in accordance with relevant legislation and regulations
- Identify, establish and routinely observe essential requirements for the maintenance of clinical and practitioner hygiene
- Anticipate potential sensitivities of the client, adapt approach is adapted accordingly to take these into account and take steps to ensure the client's dignity is maintained at all times
- Assess client through palpation, observation and sensory information gathering techniques
- Identify contra-indications to treatment