Unit of competency Outline
Information current as of
20/10/2026 7:28 AM AWST
20/10/2026 7:28 AM AWST
Whilst all efforts are made to provide accurate and timely information from the relevant source/documentation, please be aware that the information supplied may not be the most current version. The accuracy of the detail has not been confirmed by the Department and therefore should not be relied upon without first confirming the contents.
Provide inpatient care
Provide inpatient care
Unit of competency
National Code
HLTDEFHC405B
HLTDEFHC405B
State Code
D8165
D8165
TGA Status
Replaced
Replaced
DTWD Status
Deleted
Deleted
State Implementation and Classification
Approved Date
02/08/2011
Original Release Date
25/03/2011
Nominal Hours
60
Field of Education
060301 - General Nursing
Description
DescriptorThis unit covers the competency required to contribute to the provision of client care in the inpatient care setting as a member of an inpatient care teamIt includes conducting a client assessment and formulating an inpatient diagnosis, contributing to the development of an inpatient care plan and implementing the plan in order to assist the client to perform activities of daily living
General notes
N/A
Elements and Performance Criteria
1. Assess the inpatient
- 1.1 Admit client to the inpatient care facility in accordance with organisation policies and procedures
- 1.2 Prepare for inpatient assessment in accordance with clinical guidelines, codes and organisation policies and procedures
- 1.3 Obtain and record client history in order to gather data to contribute to the inpatient assessment
- 1.4 Follow personal hygiene and infection control procedures
- 1.5 Conduct physical examination in order to gather data to contribute to the inpatient assessment
2. Formulate an inpatient diagnosis
- 2.1 Analyse data gathered during the inpatient assessment in order to recognise abnormal trends for comparison with normal health patterns
- 2.2 Interpret analysed data to establish what information has clinical significance in relation to the client's health status
- 2.3 Organise data of clinical significance into meaningful clusters to focus on correct identification of any health problem(s)
- 2.4 Formulate inpatient diagnosis based on the analysis, interpretation and clustering of clinically significant data and determined health problem(s)
3. Formulate the inpatient care plan
- 3.1 Establish inpatient care goals to determine the objectives for the inpatient care plan
- 3.2 Establish expected outcomes of inpatient care to measure the progress of the inpatient care plan
- 3.3 Establish priorities for inpatient care to anticipate and sequence therapeutic interventions
- 3.4 Determine therapeutic interventions considering activities of daily living, care priorities and expected outcomes
- 3.5 Integrate special needs of the client into the inpatient care plan
- 3.6 Use relevant clinical pathways in the inpatient care plan
- 3.7 Determine discharge plan considering expected outcomes, support systems and ability to meet activities of daily living
- 3.8 Obtain authorisation of inpatient care plan by clinical supervisor
4. Implement inpatient care
- 4.1 Coordinate activities of the client, health care providers and significant others in order to implement the inpatient care plan
- 4.2 Implement care in accordance with the inpatient care plan, therapeutic interventions, clinical guidelines, codes and organisation policies and procedures
- 4.3 Monitor and record client response to inpatient care in accordance with organisation policies and procedures
- 4.4 Report inpatient response other than expected outcomes to clinical supervisor
5. Evaluate inpatient care
- 5.1 Measure therapeutic interventions against the goals and expected outcomes in order to amend the inpatient care plan
- 5.2 Measure inpatient progress against goals and expected outcomes of the inpatient care plan
- 5.3 Amend inpatient diagnosis based on inpatient progress and response to therapeutic interventions
- 5.4 Reformulate inpatient care plan based on amended inpatient diagnosis
RANGE STATEMENT
The Range Statement relates to the unit of competency as a whole. It allows for different work environments and situations that may affect performance. Add any essential operating conditions that may be present with training and assessment depending on the work situation, needs of the candidate, accessibility of the item, and local industry and regional contexts.
Inpatient care may include:
Applying occupational health and safety policies
Applying personal hygiene and infection control policy and procedures
Communicating effectively with clients and significant others
Dealing with conflict and challenging situations in a thoughtful and appropriate manner
Maintaining client confidentiality
Meeting duty of care
Performing therapeutic interventions
Providing first aid and responding to emergency situations
Providing specific and appropriate information to clients and significant others
Participating in client handover activities, ward rounds to insure continuity of care
Supporting client administration
Working effectively with others in the workplace in a team situation
Activities of daily living include:
Breathing
Communicating
Controlling body temperature
Dying
Eating and drinking
Eliminating waste
Expressing sexuality
Maintaining a safe environment
Mobilising
Personal cleansing and dressing
Sleeping
Working and playing
Clinical guidelines, codes and organisation policies and procedures may include:
ADF Nursing policy and procedure manuals
Clinical standards
Codes of ethics
Codes of practice
Industry professional bodies standards
Industry standards (state and national)
Organisation health policy directives
Relevant Australian standards
Relevant Commonwealth Acts
Standards for nursing practice
Standards for client care
Admitting the client may include:
Advising staff of the client's arrival
Allocating and preparing bed and room
Checking client identity with details on admission referral
Explaining the admission procedure to the client
Organising client belongings and valuables
Orientating the client to the facility
Preparing inpatient documentation
Welcoming and establishing a rapport with client and significant others
Assessment of the inpatient includes:
Obtaining subjective and objective relevant clinical data
Clinical data gathered from:
nursing history
physical examination
diagnostic testing
validating gathered data
Personal hygiene and infection control procedures may include:
Australian and state standards and legislation
Industry standards
Organisation procedures
Standard precautions such as hand washing procedures
Direct instructions from supervisor
Preparing an inpatient assessment may include:
Assessing the environment for suitability to conduct an inpatient assessment
Selecting and assembling equipment and supplies
Checking and calibrating equipment ready for use
Accessible information, including required forms
Explained the assessment procedure clearly and simply to the client in order to clarify its purpose and structure
Gaining informed consent from the client where applicable
Given the client the opportunity to ask questions and discuss concerns
Assuring and maintaining confidentiality of client information
Using personal protective equipment as required
Client history may include:
Biographical information:
gender
name
personal identification number
date of birth
address
occupation
marital status
next of kin
Physical information:
perception of health status
past health problems and therapies
present health therapies
risk factors
activity and coordination
review of systems
developmental stage
effect of health status on developmental stage
ability to complete activities of daily living
Emotional information:
behavioural and emotional status
support systems
self concept
body image
mood
sexuality
coping mechanisms
Social information:
financial status
recreational activities
primary language
cultural influences
environmental risk factors
social relationships
Intellectual information:
intellectual performance
problem solving ability
educational level
communication patterns
attention spans
long-term and recent memory
Spiritual information:
beliefs and meaning
religious experiences
rituals and practices
Physical examination may include:
Appropriate manoeuvres
Auscultation
Inspection
Palpation
Percussion
Relevant clinical measurements
Relevant vital signs
An inpatient diagnosis may include:
Diagnostic label (the problem e.g. constipation)
Related factors (the cause e.g. inadequate dietary fibre)
Inpatient care goals may be:
Allocated against each diagnosis
Expressed in behavioural terms
Short term or long term
Observable and measurable
Outcomes or results which are expected as a consequence of inpatient care
Realistic and attainable
Inpatient care expected outcomes are:
A measurable change of a client's health status in response to inpatient care
A projected time span for goal attainment and an opportunity to state additional resources which may be required in the care plan
Guideposts to determine when specific client centred goals have been met
Observable client behaviour and measurable criteria for inpatient care goals
Used as criteria to evaluate the effectiveness of nursing activities
A desired response of a client's condition in the following dimensions:
physical
social
emotional
developmental
spiritual
Establishing inpatient care priorities includes:
Balancing the client care priorities of:
physiological needs
sociocultural needs
psychological needs
Ranking the diagnosis in order of importance based on client's:
health desires
physiological needs
safety
Prioritising inpatient care into:
high priority needs
intermediate priority needs
low priority needs
Therapeutic interventions includes activities to meet the following:
Blood circulation needs
Comfort, rest and sleep needs
Elimination needs
Fluid and electrolyte needs
Hygiene needs
Movement and exercise needs
Nutritional needs
Oxygen needs
Psychosocial and communication needs
Safety and protection needs
Temperature regulation needs
The needs of the dying
Special needs may include:
Appropriate staff ratios/training/expertises
Cultural/spiritual/social needs
Individual differences/needs/wants/abilities
Impaired communication skills and techniques
Isolation or barrier nursing needs
Mobility and immobility needs
Sensory alterations
Specific equipment/apparatus requirements
Skin integrity and wound care needs
Surgical/rehabilitative/palliative needs
Clinical pathway may include:
Guide to best practice management for all clinical staff associated with the care of the client
Multidisciplinary treatment plan
Pre-determined type of intervention against a desired outcome
Sequenced therapeutic intervention over a projected time frame for a specific nursing diagnosis
Discharge plan may include:
Estimating the client's functional potential (activities of daily living) and planning with this in mind
Involving the client and significant others in planning the discharge
Organising referral to the appropriate health care agency or family who will assist the client with continuing care
Planning for care in another setting including access to support services
Planning to maintain continuity of care including access to specialist equipment and resources
Pre-discharge client education
Providing adequate notice to client and significant others
Providing the client information about their treatment and condition
Planning with the client ways and methods to overcome potential problems that may arise post discharge
Significant others may include:
Client's direct or indirect family members
Client's friends or close associates
Client's work colleagues
The Range Statement relates to the unit of competency as a whole. It allows for different work environments and situations that may affect performance. Add any essential operating conditions that may be present with training and assessment depending on the work situation, needs of the candidate, accessibility of the item, and local industry and regional contexts.
Inpatient care may include:
Applying occupational health and safety policies
Applying personal hygiene and infection control policy and procedures
Communicating effectively with clients and significant others
Dealing with conflict and challenging situations in a thoughtful and appropriate manner
Maintaining client confidentiality
Meeting duty of care
Performing therapeutic interventions
Providing first aid and responding to emergency situations
Providing specific and appropriate information to clients and significant others
Participating in client handover activities, ward rounds to insure continuity of care
Supporting client administration
Working effectively with others in the workplace in a team situation
Activities of daily living include:
Breathing
Communicating
Controlling body temperature
Dying
Eating and drinking
Eliminating waste
Expressing sexuality
Maintaining a safe environment
Mobilising
Personal cleansing and dressing
Sleeping
Working and playing
Clinical guidelines, codes and organisation policies and procedures may include:
ADF Nursing policy and procedure manuals
Clinical standards
Codes of ethics
Codes of practice
Industry professional bodies standards
Industry standards (state and national)
Organisation health policy directives
Relevant Australian standards
Relevant Commonwealth Acts
Standards for nursing practice
Standards for client care
Admitting the client may include:
Advising staff of the client's arrival
Allocating and preparing bed and room
Checking client identity with details on admission referral
Explaining the admission procedure to the client
Organising client belongings and valuables
Orientating the client to the facility
Preparing inpatient documentation
Welcoming and establishing a rapport with client and significant others
Assessment of the inpatient includes:
Obtaining subjective and objective relevant clinical data
Clinical data gathered from:
nursing history
physical examination
diagnostic testing
validating gathered data
Personal hygiene and infection control procedures may include:
Australian and state standards and legislation
Industry standards
Organisation procedures
Standard precautions such as hand washing procedures
Direct instructions from supervisor
Preparing an inpatient assessment may include:
Assessing the environment for suitability to conduct an inpatient assessment
Selecting and assembling equipment and supplies
Checking and calibrating equipment ready for use
Accessible information, including required forms
Explained the assessment procedure clearly and simply to the client in order to clarify its purpose and structure
Gaining informed consent from the client where applicable
Given the client the opportunity to ask questions and discuss concerns
Assuring and maintaining confidentiality of client information
Using personal protective equipment as required
Client history may include:
Biographical information:
gender
name
personal identification number
date of birth
address
occupation
marital status
next of kin
Physical information:
perception of health status
past health problems and therapies
present health therapies
risk factors
activity and coordination
review of systems
developmental stage
effect of health status on developmental stage
ability to complete activities of daily living
Emotional information:
behavioural and emotional status
support systems
self concept
body image
mood
sexuality
coping mechanisms
Social information:
financial status
recreational activities
primary language
cultural influences
environmental risk factors
social relationships
Intellectual information:
intellectual performance
problem solving ability
educational level
communication patterns
attention spans
long-term and recent memory
Spiritual information:
beliefs and meaning
religious experiences
rituals and practices
Physical examination may include:
Appropriate manoeuvres
Auscultation
Inspection
Palpation
Percussion
Relevant clinical measurements
Relevant vital signs
An inpatient diagnosis may include:
Diagnostic label (the problem e.g. constipation)
Related factors (the cause e.g. inadequate dietary fibre)
Inpatient care goals may be:
Allocated against each diagnosis
Expressed in behavioural terms
Short term or long term
Observable and measurable
Outcomes or results which are expected as a consequence of inpatient care
Realistic and attainable
Inpatient care expected outcomes are:
A measurable change of a client's health status in response to inpatient care
A projected time span for goal attainment and an opportunity to state additional resources which may be required in the care plan
Guideposts to determine when specific client centred goals have been met
Observable client behaviour and measurable criteria for inpatient care goals
Used as criteria to evaluate the effectiveness of nursing activities
A desired response of a client's condition in the following dimensions:
physical
social
emotional
developmental
spiritual
Establishing inpatient care priorities includes:
Balancing the client care priorities of:
physiological needs
sociocultural needs
psychological needs
Ranking the diagnosis in order of importance based on client's:
health desires
physiological needs
safety
Prioritising inpatient care into:
high priority needs
intermediate priority needs
low priority needs
Therapeutic interventions includes activities to meet the following:
Blood circulation needs
Comfort, rest and sleep needs
Elimination needs
Fluid and electrolyte needs
Hygiene needs
Movement and exercise needs
Nutritional needs
Oxygen needs
Psychosocial and communication needs
Safety and protection needs
Temperature regulation needs
The needs of the dying
Special needs may include:
Appropriate staff ratios/training/expertises
Cultural/spiritual/social needs
Individual differences/needs/wants/abilities
Impaired communication skills and techniques
Isolation or barrier nursing needs
Mobility and immobility needs
Sensory alterations
Specific equipment/apparatus requirements
Skin integrity and wound care needs
Surgical/rehabilitative/palliative needs
Clinical pathway may include:
Guide to best practice management for all clinical staff associated with the care of the client
Multidisciplinary treatment plan
Pre-determined type of intervention against a desired outcome
Sequenced therapeutic intervention over a projected time frame for a specific nursing diagnosis
Discharge plan may include:
Estimating the client's functional potential (activities of daily living) and planning with this in mind
Involving the client and significant others in planning the discharge
Organising referral to the appropriate health care agency or family who will assist the client with continuing care
Planning for care in another setting including access to support services
Planning to maintain continuity of care including access to specialist equipment and resources
Pre-discharge client education
Providing adequate notice to client and significant others
Providing the client information about their treatment and condition
Planning with the client ways and methods to overcome potential problems that may arise post discharge
Significant others may include:
Client's direct or indirect family members
Client's friends or close associates
Client's work colleagues
EVIDENCE GUIDE
The evidence guide provides advice on assessment and must be read in conjunction with the Performance Criteria, Required Skills and Knowledge, the Range Statement and the Assessment Guidelines for this Training Package.
Critical aspects for assessment and evidence required to demonstrate this competency unit:
The individual being assessed must provide evidence of specified essential knowledge as well as skills
Consistency of performance should be demonstrated over the required range of situations relevant to the work
Where, for reasons of safety, space, or access to equipment and resources, assessment takes place away from the work context, the assessment environment should represent work conditions as closely as possible
Resource implications
Assessment requires access to:
appropriate equipment
relevant clinical guidelines and organisation policies and procedures
working inpatient facility
inpatients
Consistency in performance
Competency should be demonstrated over time with a range of inpatient care situations that could be expected in the workplace
Access and equity considerations:
All workers in the health industry should be aware of access and equity issues in relation to their own area of work
All workers should develop their ability to work in a culturally diverse environment
In recognition of particular health issues facing Aboriginal and Torres Strait Islander communities, workers should be aware of cultural, historical and current issues impacting on health of Aboriginal and Torres Strait Islander people
Assessors and trainers must take into account relevant access and equity issues, in particular relating to factors impacting on health of Aboriginal and/or Torres Strait Islander clients and communities
Related units:
This unit may be assessed independently, but holistic assessment with other clinical units is encouraged
The evidence guide provides advice on assessment and must be read in conjunction with the Performance Criteria, Required Skills and Knowledge, the Range Statement and the Assessment Guidelines for this Training Package.
Critical aspects for assessment and evidence required to demonstrate this competency unit:
The individual being assessed must provide evidence of specified essential knowledge as well as skills
Consistency of performance should be demonstrated over the required range of situations relevant to the work
Where, for reasons of safety, space, or access to equipment and resources, assessment takes place away from the work context, the assessment environment should represent work conditions as closely as possible
Resource implications
Assessment requires access to:
appropriate equipment
relevant clinical guidelines and organisation policies and procedures
working inpatient facility
inpatients
Consistency in performance
Competency should be demonstrated over time with a range of inpatient care situations that could be expected in the workplace
Access and equity considerations:
All workers in the health industry should be aware of access and equity issues in relation to their own area of work
All workers should develop their ability to work in a culturally diverse environment
In recognition of particular health issues facing Aboriginal and Torres Strait Islander communities, workers should be aware of cultural, historical and current issues impacting on health of Aboriginal and Torres Strait Islander people
Assessors and trainers must take into account relevant access and equity issues, in particular relating to factors impacting on health of Aboriginal and/or Torres Strait Islander clients and communities
Related units:
This unit may be assessed independently, but holistic assessment with other clinical units is encouraged
Replaces
| State Code | National Code | Title | Type |
|---|---|---|---|
| C9171 | HLTDEFHC405A | Provide inpatient care | Unit of competency |
