Application

This unit describes the performance outcomes, skills and knowledge required to establish an understanding of human anatomy and physiology, diseases and conditions and surgical procedures and interventions in order to interpret clinical documentation.
This unit applies to health care professionals who are responsible for interpreting and extracting patient clinical information for the purposes of providing health care services. Work may be performed as an individual or as part of a team under limited supervision.
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.

What You'll Learn

Assessment Requirements

Performance Evidence

Evidence of the ability to complete tasks outlined in elements and performance criteria of this unit in the context of the job role, and:
• source and interpret clinical information on diseases and conditions affecting each of the body systems and specialities including:
• infectious and parasitic diseases
• neoplasms
• diseases of the blood and blood-forming organs and common disorders involving the immune mechanism
• endocrine, nutritional and metabolic diseases
• mental and behavioural disorders
• diseases of the nervous system
• diseases of the eye and adnexa
• diseases of the ear and mastoid process
• diseases of the circulatory system
• diseases of the respiratory system
• diseases of the digestive system
• diseases of the skin and subcutaneous tissue
• diseases of the musculoskeletal system and connective tissue
• diseases of the genitourinary system
• pregnancy, childbirth and the puerperium conditions originating in the perinatal period including congenital malformations, deformations and chromosomal abnormalities
• symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified
• injury, poisoning and other causes of morbidity and mortality
• for each of the diseases or conditions above, interpret clinical information to:
• identify the investigations or interventions used to diagnose the disease or condition
• identify medical and surgical interventions used to treat the disease or condition.

Knowledge Evidence

Demonstrated knowledge required to complete the tasks outlined in elements and performance criteria of this unit:
• common diseases and conditions affecting each of the following body systems and specialities including:
• infectious and parasitic diseases
• neoplasms
• diseases of the blood and blood-forming organs and common disorders involving the immune mechanism
• endocrine, nutritional and metabolic diseases
• mental and behavioural disorders
• diseases of the nervous system
• diseases of the eye and adnexa
• diseases of the ear and mastoid process
• diseases of the circulatory system
• diseases of the respiratory system
• diseases of the digestive system
• diseases of the skin and subcutaneous tissue
• diseases of the musculoskeletal system and connective tissue
• diseases of the genitourinary system
• pregnancy, childbirth and the puerperium conditions originating in the perinatal period including congenital malformations, deformations and chromosomal abnormalities
• symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified
• injury, poisoning and other causes of morbidity and mortality
• common surgical procedures, interventions and pharmacotherapy used to treat diseases and conditions of the human body system
• concepts underpinning human anatomy and physiology to enable accurate interpretation of clinical information including:
• levels of structural organisation of body systems
• human life processes
• homeostasis and the relationship between homeostatic imbalance and disease
• medical references and resources used for interpreting clinical information, including:
• medical dictionary
• drug handbook
• organisational policies and procedures relevant to health care service.

Assessment Conditions

Skills must be demonstrated in the workplace or in a simulated environment that reflects workplace conditions.
Assessment must ensure access to:
• suitable drug handbook
• reference materials, including an appropriate medical dictionary or other equivalent medical resource
Assessors must satisfy the Standards for Registered Training Organisations’ requirements for assessors.

Foundation Skills

• {'skill': 'Foundation Skills', 'description': 'Foundation skills essential to performance are explicit in the performance criteria of this unit of competency.'}

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