Clinical assessment and examination (5cr)

Objective

The purpose is to strengthen your autonomous and independent health assessment and clinical decision-making skills. The course deepens your history taking skills and physical examination techniques needed to perform a safe, comprehensive patient assessment.

Competences: Learning to learn, health assessment, and direct clinical care

By the end of the course, you demonstrate advanced skills and knowledge in history taking and holistic clinical examination. You can make valid evidence-based conclusions about the client’s, patient’s state of health and illness by using anamnesis, clinical examination, and, where applicable, laboratory tests as the basis for independent clinical decision-making (including differential diagnosis). You are able to acquire, critically assess, and produce information from the perspective of different fields. You master the documentation of patient`s, client´s individual situation and assess the fulfillment of the goals of the care plan. You understand the limits of your area of responsibility and consult other experts if necessary. You can assess and develop your expertise diversely and in a goal-oriented manner.

Content

The principles of structured health history taking

The techniques of physical examination

Complete physical examination (e.g. examination of the cardiovascular system, respiratory system, abdominal area, eye, ear, nose and throat, and musculoskeletal examination)

Clinical decision-making

Teleconsultation

Documentation

Qualifications

Bachelor's degree in nursing

Assessment criteria, satisfactory (1)

Adequate 1
You master the basics of anatomy, physiology and pathophysiology. You are aware of the methods for assessing the need for treatment and for clinical examination in your area of expertise.

You recognize changes in the client’s/patient’s state of health and are able to draw conclusions on the patient’s state of health within the limits of your area of expertise and job description. You recognize the consultation needs in a multi-professional team.

You are able to document the findings concerning the patient’s/client’s state of health.

Satisfactory 2
You master the basics of anatomy, physiology and pathophysiology and are able to utilize them in your decision-making. You are familiar with the principal methods for assessing the need for treatment and for clinical examination in your area of expertise.

You recognize changes in the client’s/patient’s state of health and are able to draw conclusions on the patient’s state of health within the limits of your area of expertise and job description. You recognize the consultation needs in a multi-professional team.

You are able to document the findings concerning the patient’s/client’s state of health.

Assessment criteria, good (3)

Good 3
You have good knowledge of anatomy, physiology and pathophysiology. You master the principal methods for assessing the need for treatment and for clinical examination in your area of expertise.

You recognize changes in the client’s/patient’s state of health and are able to draw conclusions based on evidence-based information. You utilize consultation in a multi-professional team.
You document the findings and further actions concerning the patient’s/client’s state of health complete with reasoning.

Very good 4
You have good knowledge of anatomy, physiology and pathophysiology and apply them in the assessment of the need for treatment. You master the principal methods for assessing the need for treatment and for clinical examination in your area of expertise.

You recognize changes in the client’s/patient’s state of health and are able to draw conclusions based on evidence-based information. You consider the differential-diagnostic options.

You utilize consultation in a multi-professional team.
You document the findings concerning the patient’s/client’s state of health complete with reasoning.

Assessment criteria, excellent (5)

Excellent 5
You have advanced and extensive knowledge of anatomy, physiology and pathophysiology and apply them in the assessment of the need for treatment. You master the principal methods for assessing the need for treatment with regard to several patient groups.

You recognise changes in the state of health of clients/patients of different ages and master evidence-based decision-making also in unpredictable situations. You posses differential-diagnostic reasoning skills and are able to consider different treatment options.

You utilize consultation in a multi-professional team. You document the findings and further actions concerning the patient’s/client’s state of health complete with reasoning.