Unit of competency Outline

Date retreived
22/07/2026 6:40 AM AWST

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Conduct clinical assessments

Conduct clinical assessments

Unit of competency
National Code
HLTENN020
State Code
AVZ97
TGA Status
Replaced
DTWD Status
Replaced
Current Release Number
1.00
Current Release Date
08/12/2015
View on TGA
State Implementation and Classification
Approved Date
22/06/2016
Field of Education
060301 - General Nursing
Original Release Date
22/06/2016
Nominal Hours
70
Description
This unit describes the skills and knowledge required to recongise the need for assessment, perform physical examinations and make clinical judgments using critical analysis and specialised knowledge of pathophysiology and clinical assessment processes.This unit applies to enrolled nurses, registered with the Nursing and Midwifery Board of Australia, seeking specialisation in enrolled nurse work that is carried out in consultation and collaboration with registered nurses and under direct or indirect supervisory arrangements aligned to the Nursing and Midwifery Board of Australia regulatory authority legislative requirements.The skills in this unit must be applied in accordance with Commonwealth and State/Territory legislation, Australian/New Zealand standards and industry codes of practice.
Notes
Elements and Performance Criteria
1. Recognise the need for clinical assessment
  • 1.1 Apply specialised knowledge of pathophysiology of body systems to make informed judgement on a person’s actual and potential health problems
  • 1.2 Source and interpret a person’s presenting clinical health data to identify homeostasis imbalance indicating abnormal functioning of body systems
  • 1.3 Use interviewing and active listening skills to identify, clarify and confirm health information with the person or carer prior to assessment
2. Perform physical examinations
  • 2.1 Prepare the person for examination according to the procedure being performed and obtain consent to proceed
  • 2.2 Perform a systematic head-to-toe physical body examination using established assessment tools and techniques
  • 2.3 Respect client dignity and potential sensitivities and seek feedback on comfort levels
  • 2.4 Use ongoing questioning to gain further information from the person as examination proceeds
  • 2.5 Recognise a person’s alteration in condition and potential for deterioration and immediately communicate concerns to registered nurse
3. Make clinical judgements
  • 3.1 Use a process of critical questioning and diagnostic reasoning to make links between the person’s clinical presentation and possible health condition or illness or injury
  • 3.2 Recognise the need for specific clinical interventions based on information from examination
  • 3.3 Establish priorities of care, based on assessment outcomes and judgements made
  • 3.4 Document assessment outcomes according to organisation procedures and provide information to those involved in ongoing care of the person
4. Communicate assessment outcomes
  • 4.1 Use language and terminology that the person will understand when providing results of clinical assessment
  • 4.2 Use questioning techniques to confirm with the person that the health information has been understood and address any unresolved issues with person
  • 4.3 Assess the impact of information on the person and take action accordingly
  • 4.4 Communicate outcomes and proposed actions to the registered nurse and use a collaborative approach for follow up with interdisciplinary team
No information
No information
Replaces
State Code National Code Title Type
D8231 HLTEN606B Assess clients and manage client care Unit of competency
Replaced By
State Code National Code Title Type
ODI78 HLTENN052 Provide advanced clinical assessment Unit of competency
State Code National Code Title Type
AZA2 HLT64115 Advanced Diploma of Nursing Qualification