Unit of competency Outline
Information current as of
21/10/2026 2:04 AM AWST
21/10/2026 2:04 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.
Conduct a clinical assessment
Conduct a clinical assessment
Unit of competency
National Code
HLTDEFHC403B
HLTDEFHC403B
State Code
D5865
D5865
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
50
Field of Education
060301 - General Nursing
Description
DescriptorThis unit covers the competency required to conduct a clinical assessment of a client, including obtaining and recording a medical history, conducting a physical examination and making and recording a clinical assessment of the client
General notes
N/A
Elements and Performance Criteria
1. Prepare for clinical assessment
- 1.1 Assess environment for suitability to conduct a clinical assessment
- 1.2 Select required equipment, consumables and documentation, check for serviceability and arrange for use
- 1.3 Review relevant client history
- 1.4 Use personal protective equipment as required
2. Prepare client for clinical assessment
- 2.1 Explain clinical assessment clearly and simply to the client
- 2.2 Give client is given the opportunity to ask questions and discuss concerns
- 2.3 Gain informed consent from client in accordance with clinical guidelines, organisation policies and procedures
- 2.4 Assure and maintain confidentiality of client information
3. Obtain and record a medical history and client profile
- 3.1 Ensure client is comfortable and positioned in a manner to avoid distractions
- 3.2 Interview client to gather and convey information
- 3.3 Obtain and record medical history and client profile according to clinical guidelines, organisation policies and procedures
4. Conduct a physical examination
- 4.1 Follow personal hygiene and infection control procedures
- 4.2 Measure and record vital signs in accordance with clinical guidelines, organisation policies and procedures
- 4.3 Conduct examination using appropriate physical examination techniques according to clinical guidelines, organisation policies and procedures
- 4.4 Record examination outcomes in accordance with clinical guidelines, organisation policies and procedures
5. Make a clinical assessment
- 5.1 Make clinical assessment according to applied clinical reasoning and organisation policies and procedures
- 5.2 Determine need for referral for extended physical examination and/or further diagnostic procedures
- 5.3 Use information gathered through the clinical assessment to the develop treatment plan
- 5.4 Arrange appropriate referral as required
6. Conclude clinical assessment
- 6.1 Explain clinical assessment findings clearly and simply to the client
- 6.2 Record clinical findings in a way that can be interpreted readily by others and according to clinic guidelines, organisation policies and procedures
- 6.3 Clean and/or dispose of equipment and consumables in accordance with manufacturers' requirements and infection control policy
- 6.4 Store equipment and consumables in accordance with organisation policy and procedures
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.
Environment assessment may include:
Adequate lighting
Health care practitioner's specified needs
Suitable climate
Suitable client privacy
Equipment and consumables may include:
Equipment for measuring height and weight
Examination table
Glucometer and disposable lancets devices
Goggles/protective eyewear
Goose-neck lamp or other light source
Measuring tape
Nasal speculum
Ophthalmoscope
Otoscope
Peak flow meter and disposable mouth pieces
Penlight
Percussion (reflex) hammer
Skin marking pencil
Sphygmomanometer
Stethoscope
Thermometer
Timing device
Alcohol cleansing wipes
Cotton-tipped swab
Disposable gloves
Examination gowns
Gauze squares
Half-sheet for draping
Hazard bags for infection control
Instrument cleaning supplies
Sharps containers
Tongue depressors
Visual acuity charts
Confidentiality of client information may be ensured by:
Adherence to Privacy Act
Information disclosed to an appropriate person consistent with the responsibility of this position
Legal and ethical requirements
Secure location for written records
Treatment room with privacy
Medical history and client profile may include:
Current health information including:
habits (alcohol, tobacco, drugs, caffeine)
current medication being taken
exercise, sleep and dietary patterns
Past health history (pertinent to presenting complaint) such as:
past general health
accidents and disabling injuries
major acute and chronic illnesses
past allergies
past medications
Client biographical information
Presenting complaint
Present health and illness status, such as:
client summary and usual health
onset of current condition
progression since onset
body location, quality, quantity of discomfort
alleviating or aggravating factors (environment)
disability assessment
Relevant family health history
Review of systems:
physical background
functional limitations
sociological circumstance (home, work, etc)
psychological integrity
Clinical guidelines, organisation policies and procedures may include:
ADF nursing procedure manual
ADF treatment protocols
Clinical standards (state and national)
Industry professional bodies
Industry standards (state and national)
Organisation policy directives
Privacy Act
Relevant Australian standards
Measuring vital signs may include:
Following standardised procedures for infection control
Measuring blood pressure, respiration and pulse rates, and temperature
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
Physical examination techniques include:
Appropriate manoeuvres
Use of examination equipment
Auscultation
Inspection
Palpation
Percussion
Applied clinical reasoning includes:
Collecting clinical data (interview, medical history, physical examination, clinical measurements)
Organising data (recognising key diagnostic data, validating data, clustering data into a clinical pattern)
Making the clinical assessment
Linking the assessment to the treatment plan
Need for referral may include:
Need for higher medical diagnostic information or procedures
Signs of notifiable disease
Suspected dangerous pathology
Unknown symptom complex or condition
Identified condition outside of own scope of management
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.
Environment assessment may include:
Adequate lighting
Health care practitioner's specified needs
Suitable climate
Suitable client privacy
Equipment and consumables may include:
Equipment for measuring height and weight
Examination table
Glucometer and disposable lancets devices
Goggles/protective eyewear
Goose-neck lamp or other light source
Measuring tape
Nasal speculum
Ophthalmoscope
Otoscope
Peak flow meter and disposable mouth pieces
Penlight
Percussion (reflex) hammer
Skin marking pencil
Sphygmomanometer
Stethoscope
Thermometer
Timing device
Alcohol cleansing wipes
Cotton-tipped swab
Disposable gloves
Examination gowns
Gauze squares
Half-sheet for draping
Hazard bags for infection control
Instrument cleaning supplies
Sharps containers
Tongue depressors
Visual acuity charts
Confidentiality of client information may be ensured by:
Adherence to Privacy Act
Information disclosed to an appropriate person consistent with the responsibility of this position
Legal and ethical requirements
Secure location for written records
Treatment room with privacy
Medical history and client profile may include:
Current health information including:
habits (alcohol, tobacco, drugs, caffeine)
current medication being taken
exercise, sleep and dietary patterns
Past health history (pertinent to presenting complaint) such as:
past general health
accidents and disabling injuries
major acute and chronic illnesses
past allergies
past medications
Client biographical information
Presenting complaint
Present health and illness status, such as:
client summary and usual health
onset of current condition
progression since onset
body location, quality, quantity of discomfort
alleviating or aggravating factors (environment)
disability assessment
Relevant family health history
Review of systems:
physical background
functional limitations
sociological circumstance (home, work, etc)
psychological integrity
Clinical guidelines, organisation policies and procedures may include:
ADF nursing procedure manual
ADF treatment protocols
Clinical standards (state and national)
Industry professional bodies
Industry standards (state and national)
Organisation policy directives
Privacy Act
Relevant Australian standards
Measuring vital signs may include:
Following standardised procedures for infection control
Measuring blood pressure, respiration and pulse rates, and temperature
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
Physical examination techniques include:
Appropriate manoeuvres
Use of examination equipment
Auscultation
Inspection
Palpation
Percussion
Applied clinical reasoning includes:
Collecting clinical data (interview, medical history, physical examination, clinical measurements)
Organising data (recognising key diagnostic data, validating data, clustering data into a clinical pattern)
Making the clinical assessment
Linking the assessment to the treatment plan
Need for referral may include:
Need for higher medical diagnostic information or procedures
Signs of notifiable disease
Suspected dangerous pathology
Unknown symptom complex or condition
Identified condition outside of own scope of management
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:
Assessment must confirm the ability to :
Resource implications
Assessment requires access to:
appropriate equipment
scenarios that reflect a range of clinical assessments that may be expected in the workplace
reference texts
local legal guidelines
Consistency in performance
Competency should be demonstrated over time with a range of clinical assessments that could be expected in the workplace
Context of assessment
Competency should be assessed in the workplace or in a simulated 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 should be assessed in conjunction with this unit:
HLTDEFHC408B Provide treatments for common conditions
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:
Assessment must confirm the ability to :
Resource implications
Assessment requires access to:
appropriate equipment
scenarios that reflect a range of clinical assessments that may be expected in the workplace
reference texts
local legal guidelines
Consistency in performance
Competency should be demonstrated over time with a range of clinical assessments that could be expected in the workplace
Context of assessment
Competency should be assessed in the workplace or in a simulated 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 should be assessed in conjunction with this unit:
HLTDEFHC408B Provide treatments for common conditions
Replaces
| State Code | National Code | Title | Type |
|---|---|---|---|
| C9169 | HLTDEFHC403A | Conduct a clinical assessment | Unit of competency |
