Elements and Performance Criteria
- Determine the scope of the assessment and the client's needs
- Establish client's purpose for consultation and identify symptoms
- Determine client's eligibility for service using clinic/personal policies
- Explain clearly services provided and limits of available services
- Explore and clarity client's expectations of the service/clinic
- Identify factors likely to have a negative impact on assessment in consultation with the client and wherever possible implement strategies to minimise the effects of these factors
- Define personal abilities, level of professional competence and parameters of role to the client and ensure they determine practice at all times
- 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 information required from the client for the client's history in a respectful way asking all enquiries 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
- Manage the health assessment
- Obtain informed client consent prior to conducting tests, in accordance with relevant legislation and regulations
- Allow adequate time during consultation to gather critical information
- Identify and minimise factors that may interfere with the information gathering process
- Identify, establish and routinely observe essential requirements for the maintenance of clinical and practitioner hygiene
- Anticipate potential sensitivities of the, adapt approach accordingly to take these into account and take steps to ensure the client's dignity is maintained at all times
- Pursue and investigate abnormal findings in a deliberate, logical and appropriate manner
- Assess the reliability of data obtained and ensure appropriate clinical correlation with the client's complaints is established
- Base any decision to carry out laboratory tests on the integration of previously obtained clinical data and history
- Adhere to protocol required by the agency in ordering tests
- Accurately record all information in a systematic manner in accordance with clinic guidelines
- Prepare the client for assessment
- Make an assessment of the client
- Identify signs of condition according to TCM therapy framework
- Assess client through palpation, observation and sensory information gathering techniques
- Use other appropriate assessment techniques
- Identify contraindications to treatment
- Conduct assessment according to local regulation and legislative requirements