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Evidence Guide: HLTAHCS004 - Complete comprehensive physical health assessments

Student: __________________________________________________

Signature: _________________________________________________

Tips for gathering evidence to demonstrate your skills

The important thing to remember when gathering evidence is that the more evidence the better - that is, the more evidence you gather to demonstrate your skills, the more confident an assessor can be that you have learned the skills not just at one point in time, but are continuing to apply and develop those skills (as opposed to just learning for the test!). Furthermore, one piece of evidence that you collect will not usualy demonstrate all the required criteria for a unit of competency, whereas multiple overlapping pieces of evidence will usually do the trick!

From the Wiki University

 

HLTAHCS004 - Complete comprehensive physical health assessments

What evidence can you provide to prove your understanding of each of the following citeria?

Obtain client information and determine health assessment requirements.

  1. Complete health assessments according to scope of practice and organisational standard treatment protocols.
  2. Consult relevant health professionals and client health records to evaluate current status of client’s health and impact of any previous treatment strategies.
  3. Obtain current client medical and social history and discuss specific presenting problems using culturally appropriate and safe communication.
  4. Obtain client information about effectiveness of any current treatments and self-care strategies.
  5. Explain organisational requirements for maintaining confidentiality of information and permissions for disclosure.
  6. Accurately document client history according to organisational policies and procedures.
  7. Determine specific examination and clinical test requirements from information gathered.
Complete health assessments according to scope of practice and organisational standard treatment protocols.

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Consult relevant health professionals and client health records to evaluate current status of client’s health and impact of any previous treatment strategies.

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Obtain current client medical and social history and discuss specific presenting problems using culturally appropriate and safe communication.

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Obtain client information about effectiveness of any current treatments and self-care strategies.

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Explain organisational requirements for maintaining confidentiality of information and permissions for disclosure.

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Accurately document client history according to organisational policies and procedures.

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Determine specific examination and clinical test requirements from information gathered.

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Complete physical examination and tests.

  1. Explain the reason and procedures for each examination and test to the client, confirm understanding and obtain informed consent.
  2. Implement required infection control precautions according to examination and test requirements.
  3. Use correct protocols to measure vital signs and identify any significant variation from normal reference range.
  4. Conduct physical examination and clinical tests based on observations and client presentation, and with respect for community values, beliefs and gender roles.
  5. Use correct clinical protocols to collect, record and send specimens for pathology testing.
  6. Accurately record details of all measurements, examinations and tests according to organisational policies and procedures.
Explain the reason and procedures for each examination and test to the client, confirm understanding and obtain informed consent.

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Implement required infection control precautions according to examination and test requirements.

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Use correct protocols to measure vital signs and identify any significant variation from normal reference range.

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Conduct physical examination and clinical tests based on observations and client presentation, and with respect for community values, beliefs and gender roles.

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Use correct clinical protocols to collect, record and send specimens for pathology testing.

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Accurately record details of all measurements, examinations and tests according to organisational policies and procedures.

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Interpret, document and confirm health assessment findings.

  1. Evaluate pathology test results, check numerical test values against normal reference range and identify abnormal results.
  2. Identify, from examination results, any significant variations from normal reference range or client’s baseline and previous measurements.
  3. Evaluate significance of outcomes on the clinical progress or regression of any pre-existing client disease.
  4. Accurately identify any signs, symptoms and test results that indicate emerging or worsening disease and/or comorbidity.
  5. Determine own interpretation of client’s current health status based on history, presenting problems, examination and test results.
  6. Provide clear and accurate reports and consult with other health care team members to verify results and confirm client’s health status.
  7. Report any confirmed notifiable diseases according to procedural and legal requirements and within scope of own responsibility.
  8. Update client records with health assessment details according to organisational policies and procedures.
Evaluate pathology test results, check numerical test values against normal reference range and identify abnormal results.

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Identify, from examination results, any significant variations from normal reference range or client’s baseline and previous measurements.

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Evaluate significance of outcomes on the clinical progress or regression of any pre-existing client disease.

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Accurately identify any signs, symptoms and test results that indicate emerging or worsening disease and/or comorbidity.

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Determine own interpretation of client’s current health status based on history, presenting problems, examination and test results.

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Provide clear and accurate reports and consult with other health care team members to verify results and confirm client’s health status.

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Report any confirmed notifiable diseases according to procedural and legal requirements and within scope of own responsibility.

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Update client records with health assessment details according to organisational policies and procedures.

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Provide assessment outcomes to clients and/or significant others.

  1. Provide information about verified assessment results in plain language using culturally appropriate and safe communication.
  2. Explain significance of examination and pathology test results in the context of any pre-existing client disease and health care plan.
  3. Explain to client importance of regular check-ups and tests for the ongoing management of their health.
  4. Provide client with recommendations and referrals to assist with ongoing treatment and management of their health.
  5. Encourage client and/or significant others to question and clarify outcomes, and purpose of potential treatments and interventions.
  6. Confirm understanding and document information provided in client records.
Provide information about verified assessment results in plain language using culturally appropriate and safe communication.

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Explain significance of examination and pathology test results in the context of any pre-existing client disease and health care plan.

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Explain to client importance of regular check-ups and tests for the ongoing management of their health.

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Provide client with recommendations and referrals to assist with ongoing treatment and management of their health.

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Encourage client and/or significant others to question and clarify outcomes, and purpose of potential treatments and interventions.

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Confirm understanding and document information provided in client records.

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Assessed

Teacher: ___________________________________ Date: _________

Signature: ________________________________________________

Comments:

 

 

 

 

 

 

 

 

Instructions to Assessors

Required Skills and Knowledge