Unit of competency Outline
Date retreived
23/07/2026 5:37 AM AWST
23/07/2026 5:37 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.
Contribute to client assessment and developing nursing care plans
Contribute to client assessment and developing nursing care plans
Unit of competency
National Code
HLTEN503B
HLTEN503B
State Code
D8208
D8208
TGA Status
Replaced
Replaced
DTWD Status
Replaced
Replaced
State Implementation and Classification
Approved Date
24/08/2012
Field of Education
060307 - Community Nursing
Original Release Date
24/08/2012
Nominal Hours
80
Description
DescriptorThis unit of competency describes the skills and knowledge required of an Enrolled/Division 2 Nurse in contributing to the development of individualised health care plans by collection of data captured during a client's preliminary and ongoing health assessments. Assessment is based on a lifespan approach
Notes
Elements and Performance Criteria
1. Collect data that contributes to client health care plan
- 1.1 Ensure appropriate introductions and explanations precede all nursing assessment and interventions
- 1.2 Measure vital signs of the client using appropriate biomedical equipment according to the acuity of care and physical characteristics of the client
- 1.3 Perform other clinical measurements/assessments such as activities of daily living
- 1.4 Record lifestyle patterns and coping mechanisms in documentation
- 1.5 Document current client health practices, issues and needs
- 1.6 Document gender, age, cultural, religious and/or spiritual data in preliminary health assessment
- 1.7 Identify the likely impact of specific health care on the client's health
- 1.8 Involve client in the process of data collection wherever possible
- 1.9 Access client information from appropriate family member or carer (if client is unable)
- 1.10 Identify the emotional and physical needs of family and significant others in supporting the client
- 1.11 Document and report variations from normal on a regular basis
- 1.12 Validate extraordinary findings immediately, document and report abnormalities to the registered nurse
- 1.13 Undertake ongoing client assessment
2. Undertake client assessment for admission and discharge
- 2.1 Collect client-based data for admission and /or discharge planning
- 2.2 Communicate effectively with clients, family and health team members within jurisdictional scope of practice
- 2.3 Contribute to nursing assessment documentation relating to physical, psychosocial and contextual client factors
- 2.4 Follow organisation policies and procedures relating to client participation
- 2.5 Undertake client admission with understanding of processes involved and key issues to be addressed
- 2.6 Take into account individual's values and attitudes regarding health care and any issues the client may be experiencing and report to the registered nurse, as appropriate
- 2.7 Document client information, such as community resources, to assist in planning for discharge
- 2.8 Accurately record and report admission and discharge information
3. Analyse client health assessment data and observations
- 3.1 Accurately interpret information gained from health assessments and observations as being within normal range and/or refer to appropriate health care colleague for interpretation
- 3.2 Report change in client health status in a timely manner to the appropriate health care colleague
- 3.3 Identify the likely cause of any significant variation(s) from normal in relation to providing care
- 3.4 Reflect consideration for age and developmental state of client in performance of clinical nursing assessment
- 3.5 Analyse physiological aspects of human growth and its impact on client health
- 3.6 Reflect the client's interests, physical, emotional and psychosocial needs in documentation
- 3.7 Respect cultural, spiritual and religious wishes during nursing assessment
- 3.8 Use client health history as part of planning care in line with health organisation requirements
4. Contribute to the development of individual care plans for clients
- 4.1 Conduct a holistic health assessment reflecting the nursing philosophy or theory of the organisation in consultation/collaboration with a registered nurse
- 4.2 Use appropriate health assessment tools and appropriate terminology in documentation as well as a variety of sources and clinical situations
- 4.3 Use a problem solving approach in the development of care plans for clients
- 4.4 Discuss care requirements with the client and/or their family or significant other to ensure information is accurate
- 4.5 Verify client based information to ensure client's uniqueness and individuality is reflected in the care plan
- 4.6 Develop, implement and evaluate contingency plans and care plans in consultation/collaboration with the registered nurse
- 4.7 Record age and gender issues in the development of individualised care plans
- 4.8 Incorporate cultural, spiritual and religious beliefs in the development of individualised care plans
- 4.9 Ensure documentation reflect the client's needs: physical, emotional, spiritual and psychosocial
- 4.10 Ensure nursing care plan addresses principles of best practice and risk assessment and identifies stress management techniques for clients
5. Prepare for client discharge
- 5.1 Identify appropriate community support services to the client
- 5.2 Promote client awareness and understanding through health education within the Enrolled/Division 2 nurse scope of practice
- 5.3 Ensure client has all requirements for discharge: next GP's appointment; medications; and any referrals
- 5.4 Ensure documentation is completed as per policy and procedure
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.
Preliminary health assessment data collected may include:
Allergies
Biographical information
Client and/or family concerns regarding the illness or disease
Co-existing health problems
Current lifestyle patterns and behaviours
Environmental factors and living circumstances
Family history of presenting illness or disease in addition to length of symptoms
Immunisation status
Medications
Past medical or surgical condition
Presenting condition
Clinical nursing interventions or observations include:
Blood glucose level
Blood pressure
Body mass index
Height and weight
Neurological observations
Performance of activities of daily living
Sensory perception
Skin colour, integrity and turgor
Temperature/pulse/respirations
Urinalysis
Age and gender considerations could include:
Age of consent
Body image perceptions
Confidentiality
Female health concerns
Male health concerns
Maturation and physical development
Need for parental consent
Self esteem
Cultural, spiritual or religious data could include:
Cultural practices
Culturally appropriate nursing actions
Need for interpreter services
Religious beliefs
Spiritual beliefs
Views on health and illness
Common terms associated with human behaviour may include:
Achievement
Affect
Emotion
Mood
Motivation
Perception
Sensation
Factors that influence health related behaviour may include:
age
Culture
Economic
Educational
Environmental
Gender
Geographical
Physiological
Psychological
Social
The concepts of growth and development may include:
Cephalocaudal
Cognitive
Emotional
Inclusive
Interdependent
Physical
Proximo-distal
Simple to complex
Social
The theorists associated with theories of growth and development may include:
Erikson
Freud
Havighurst
Maslow
Piaget
Cognitive and motor development of infants (0 -1) may include:
Attachment and Bonding
Emotional development - from excitement to jealousy
Gross motor skills: rolling, crawling, walking
Language development
Memory
Object permanence
Percentile charts
Reflexes
Relationship development
Spatial relationships
Time
Toddler's development may include:
Assist rather than instruct
Beginnings of independence and autonomy
Cause and effect
Completion of simple puzzles
Fine motor skills pencil grip, using scissors, pulling up pants, washing hands
Gross motor skills: walking, running, climbing, riding tricycles
Love and affection
Object permanence developing
Offering choices
Play alongside other children
Routines
Safe environment
Self feeding
continued ...
Toddler's development may include (cont):
Sensitivity from adults
Slow down of physical growth
Speech
Temper tantrums
Toilet training
Preschooler's development may include:
Construction activities
Development of fears: dark, accidents
Egocentric
Endless questioning
Fine motor skills: cutting, painting, drawing
Gross motor skills: running, climbing, jumping, throwing, catching
Increasing language skills: chatter, sing
Learning requires the use of physical materials integrated into real life situations
Need for exploration with in a safe environment
Physical growth increases
Playing with other children, actively looking for playmates
Pre - operational phase (Piaget)
Require acceptance and encouragement
Rich and creative imagination
Routines
Safe environment
Social interactions
School aged child's development may include:
Abstract and more flexible thought
Appearance of secondary sexual characteristics
Concrete operational phase (Piaget)
Cooperation
Fear, depression and detachment
Generosity
Height, weight and changes in proportion
Helpfulness
Independence
Injury prevention
Participation in team sports
Peer group
Permanent teeth
Playground pecking order
Problem solving skills
Recognition of individual needs
Self concept
Self esteem
Social self
Timing and coordination
Adolescent development may include:
Abstract thinking
Appreciation for double meanings and symbolism
Body proportions
Changes in height and weight - growth spurts
Dating - behaviour, rejection and first love
Emancipation from parents
Formal operation phase (Piaget)
Formation of Personal identity
Identity V Role confusion (Erikson)
Menstruation
Muscle development
Puberty
Safety, protection and support
Self image
Sexual development
Major adolescent issues may include:
Alcohol consumption - binge drinking
Career path
Eating disorders
Employment
Gender identity
'Generation gap'
Juvenile delinquency/crime
Peer pressure
Rape
Road accidents
Safe sex
Smoking
Substance use and abuse
Teenage pregnancy
Teenage suicide
Early, middle and older adult activities may include:
'Empty Nest'
Children grow up and leave home
Community work
Community work
Contribution to society/future generations
Death of family members
Developing a career
Economic independence
Finding a partner
Grandparenthood
Marriage
Marriage disenchantment
Menopause
Mentors for younger generations
Parent hood
Reduction in Progesterone
Retirement
Nursing record or reports may include:
Care plans
Client referrals
Clinical pathways
Completion of client based assessment tools and observation charts
Computerised reporting
Drug orders
Integrated notes
Nursing notes
Resident classification records
Test results
Written instructions
Biomedical equipment may include:
ECG machine/monitor
Glass/tympanic/thermometer
Glucometer
Manual/electronic sphygmomanometer
Peak flow meter
Pencil torch
Pulse oximeter
Stethoscope
Timing device with second hand
Urine testing kit
Weighing scales
Validations of findings include:
Checking of reading with a registered nurse, as appropriate
Checks/comparisons on baseline observations
Elimination of artefacts
Use of manual versus mechanical; observations
Visual and verbal assessment of the client
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.
Preliminary health assessment data collected may include:
Allergies
Biographical information
Client and/or family concerns regarding the illness or disease
Co-existing health problems
Current lifestyle patterns and behaviours
Environmental factors and living circumstances
Family history of presenting illness or disease in addition to length of symptoms
Immunisation status
Medications
Past medical or surgical condition
Presenting condition
Clinical nursing interventions or observations include:
Blood glucose level
Blood pressure
Body mass index
Height and weight
Neurological observations
Performance of activities of daily living
Sensory perception
Skin colour, integrity and turgor
Temperature/pulse/respirations
Urinalysis
Age and gender considerations could include:
Age of consent
Body image perceptions
Confidentiality
Female health concerns
Male health concerns
Maturation and physical development
Need for parental consent
Self esteem
Cultural, spiritual or religious data could include:
Cultural practices
Culturally appropriate nursing actions
Need for interpreter services
Religious beliefs
Spiritual beliefs
Views on health and illness
Common terms associated with human behaviour may include:
Achievement
Affect
Emotion
Mood
Motivation
Perception
Sensation
Factors that influence health related behaviour may include:
age
Culture
Economic
Educational
Environmental
Gender
Geographical
Physiological
Psychological
Social
The concepts of growth and development may include:
Cephalocaudal
Cognitive
Emotional
Inclusive
Interdependent
Physical
Proximo-distal
Simple to complex
Social
The theorists associated with theories of growth and development may include:
Erikson
Freud
Havighurst
Maslow
Piaget
Cognitive and motor development of infants (0 -1) may include:
Attachment and Bonding
Emotional development - from excitement to jealousy
Gross motor skills: rolling, crawling, walking
Language development
Memory
Object permanence
Percentile charts
Reflexes
Relationship development
Spatial relationships
Time
Toddler's development may include:
Assist rather than instruct
Beginnings of independence and autonomy
Cause and effect
Completion of simple puzzles
Fine motor skills pencil grip, using scissors, pulling up pants, washing hands
Gross motor skills: walking, running, climbing, riding tricycles
Love and affection
Object permanence developing
Offering choices
Play alongside other children
Routines
Safe environment
Self feeding
continued ...
Toddler's development may include (cont):
Sensitivity from adults
Slow down of physical growth
Speech
Temper tantrums
Toilet training
Preschooler's development may include:
Construction activities
Development of fears: dark, accidents
Egocentric
Endless questioning
Fine motor skills: cutting, painting, drawing
Gross motor skills: running, climbing, jumping, throwing, catching
Increasing language skills: chatter, sing
Learning requires the use of physical materials integrated into real life situations
Need for exploration with in a safe environment
Physical growth increases
Playing with other children, actively looking for playmates
Pre - operational phase (Piaget)
Require acceptance and encouragement
Rich and creative imagination
Routines
Safe environment
Social interactions
School aged child's development may include:
Abstract and more flexible thought
Appearance of secondary sexual characteristics
Concrete operational phase (Piaget)
Cooperation
Fear, depression and detachment
Generosity
Height, weight and changes in proportion
Helpfulness
Independence
Injury prevention
Participation in team sports
Peer group
Permanent teeth
Playground pecking order
Problem solving skills
Recognition of individual needs
Self concept
Self esteem
Social self
Timing and coordination
Adolescent development may include:
Abstract thinking
Appreciation for double meanings and symbolism
Body proportions
Changes in height and weight - growth spurts
Dating - behaviour, rejection and first love
Emancipation from parents
Formal operation phase (Piaget)
Formation of Personal identity
Identity V Role confusion (Erikson)
Menstruation
Muscle development
Puberty
Safety, protection and support
Self image
Sexual development
Major adolescent issues may include:
Alcohol consumption - binge drinking
Career path
Eating disorders
Employment
Gender identity
'Generation gap'
Juvenile delinquency/crime
Peer pressure
Rape
Road accidents
Safe sex
Smoking
Substance use and abuse
Teenage pregnancy
Teenage suicide
Early, middle and older adult activities may include:
'Empty Nest'
Children grow up and leave home
Community work
Community work
Contribution to society/future generations
Death of family members
Developing a career
Economic independence
Finding a partner
Grandparenthood
Marriage
Marriage disenchantment
Menopause
Mentors for younger generations
Parent hood
Reduction in Progesterone
Retirement
Nursing record or reports may include:
Care plans
Client referrals
Clinical pathways
Completion of client based assessment tools and observation charts
Computerised reporting
Drug orders
Integrated notes
Nursing notes
Resident classification records
Test results
Written instructions
Biomedical equipment may include:
ECG machine/monitor
Glass/tympanic/thermometer
Glucometer
Manual/electronic sphygmomanometer
Peak flow meter
Pencil torch
Pulse oximeter
Stethoscope
Timing device with second hand
Urine testing kit
Weighing scales
Validations of findings include:
Checking of reading with a registered nurse, as appropriate
Checks/comparisons on baseline observations
Elimination of artefacts
Use of manual versus mechanical; observations
Visual and verbal assessment of the client
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
Observation of performance in a work context is essential for assessment of this unit
Consistency of performance should be demonstrated over the required range of workplace situations and should occur on more than one occasion and be assessed by a registered nurse
Context of and specific resources for assessment:
This unit is most appropriately assessed in the clinical workplace or in a simulated clinical work environment and under the normal range of clinical environment conditions prior to assessment in the clinical workplace
Where, for reasons of safety, access to equipment and resources and space, assessment takes place away from the workplace, simulations should be used to represent workplace conditions as closely as possible
Method of assessment
Observation in the workplace
Written assignments/projects
Case study and scenario as a basis for discussion of issues and strategies to contribute to best practice
Questioning - verbal and writing
Role play/simulation
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 is recommended to be assessed in conjunction with the following related competency unit:
HLTAP501B Analyse health information
HLTEN502B Apply effective communication skills in nursing practice
This competency unit incorporates the content of:
HLTEN403B Undertake basic client assessment
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
Observation of performance in a work context is essential for assessment of this unit
Consistency of performance should be demonstrated over the required range of workplace situations and should occur on more than one occasion and be assessed by a registered nurse
Context of and specific resources for assessment:
This unit is most appropriately assessed in the clinical workplace or in a simulated clinical work environment and under the normal range of clinical environment conditions prior to assessment in the clinical workplace
Where, for reasons of safety, access to equipment and resources and space, assessment takes place away from the workplace, simulations should be used to represent workplace conditions as closely as possible
Method of assessment
Observation in the workplace
Written assignments/projects
Case study and scenario as a basis for discussion of issues and strategies to contribute to best practice
Questioning - verbal and writing
Role play/simulation
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 is recommended to be assessed in conjunction with the following related competency unit:
HLTAP501B Analyse health information
HLTEN502B Apply effective communication skills in nursing practice
This competency unit incorporates the content of:
HLTEN403B Undertake basic client assessment
Replaces
| State Code | National Code | Title | Type |
|---|---|---|---|
| C9214 | HLTEN503A | Contribute to client assessment and developing nursing care plans | Unit of competency |
Replaced By
| 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 |
|---|---|---|---|
| D096 | HLT51607 | Diploma of Nursing (Enrolled/Division 2 nursing) | Qualification |
| J108 | HLT51612 | Diploma of Nursing (Enrolled-Division 2 nursing) | Qualification |