Unit of competency Outline

Date retreived
22/07/2026 1:17 PM AWST

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Perform clinical assessment and contribute to planning nursing care

Perform clinical assessment and contribute to planning nursing care

Unit of competency
National Code
HLTENN037
State Code
ODI53
TGA Status
Current
DTWD Status
Approved
Current Release Number
2.00
Current Release Date
02/07/2021
View on TGA
State Implementation and Classification
Approved Date
29/10/2021
Field of Education
060307 - Community Nursing
Original Release Date
29/10/2021
Nominal Hours
80
Description
This unit of competency describes the performance outcomes, skills and knowledge required, within the scope of practice, to perform preliminary and ongoing physical health assessments of all body systems, gathering data that contributes to an individualised health plan of care.This unit applies to enrolled nursing work carried out in consultation and collaboration with registered nurses, and under supervisory arrangements aligned to the Nursing and Midwifery Board of Australia (NMBA) regulatory authority legislative requirements.The skills in this unit must be applied in accordance with Commonwealth and State/Territory legislation, Australian Standards and industry codes of practice.No occupational licensing, certification or specific legislative requirements apply to this unit at the time of publication.
Notes
Elements and Performance Criteria
1. Perform admission assessment.
  • 1.1. Introduce self and explain processes before commencing nursing assessment activities.
  • 1.2. Collect and record admission information including gender, age, cultural, religious and spiritual information in accordance with organisational policies and procedures, and practice standards.
  • 1.3. Perform baseline clinical assessment and document findings including vital signs.
  • 1.4. Interpret and analyse objective and subjective assessment data against normal range.
  • 1.5. Record lifestyle patterns, health history and current health practices.
  • 1.6. Clarify emotional and physical needs of the families and carers.
  • 1.7. Document and communicate alterations and deteriorations of health status.
2. Contribute to plan of nursing care.
  • 2.1. Analyse health history and health assessment to identify risks, likely impacts on daily living activities and care needs.
  • 2.2. Use a problem-solving approach to assist comprehensive nursing care planning.
  • 2.3. Clarify and reflect the person’s interests and physical, emotional and psychosocial needs in nursing care planning and documentation.
3 Evaluate and modify plan of nursing care.
  • 3.1. Analyse, evaluate and review nursing care planning decisions with registered nurse and multidisciplinary health care team.
  • 3.2. Confirm with the person, families or carers that planned nursing care reflects their needs including their uniqueness, culture, religious beliefs and management of stress.
  • 3.3. Ensure plan of nursing care is based on principles of contemporary, evidence-based practice and incorporates risk assessment.
  • 3.4. Review and evaluate plan of nursing care to ensure care needs are met.
4. Perform discharge procedures.
  • 4.1. Collect discharge planning data.
  • 4.2. Contribute to nursing assessment and document issues to facilitate discharge.
  • 4.3. Identify community support services and resources to assist in discharge planning.
  • 4.4. Check to ensure discharge requirements are planned and updated including follow up requirements, discharge prescriptions, My Healthcare Record, referrals and reports for ongoing treatment to health practitioners.
No information
No information
Replaces
State Code National Code Title Type
AWA14 HLTENN003 Perform clinical assessment and contribute to planning nursing care Unit of competency
State Code National Code Title Type
BGW5 HLT54121 Diploma of Nursing Qualification