SAQA All qualifications and part qualifications registered on the National Qualifications Framework are public property. Thus the only payment that can be made for them is for service and reproduction. It is illegal to sell this material for profit. If the material is reproduced or quoted, the South African Qualifications Authority (SAQA) should be acknowledged as the source.
SOUTH AFRICAN QUALIFICATIONS AUTHORITY 
REGISTERED UNIT STANDARD: 

Carry out a health assessment of an individual of any age group 
SAQA US ID UNIT STANDARD TITLE
252082  Carry out a health assessment of an individual of any age group 
ORIGINATOR
SGB Nursing 
PRIMARY OR DELEGATED QUALITY ASSURANCE FUNCTIONARY
-  
FIELD SUBFIELD
Field 09 - Health Sciences and Social Services Promotive Health and Developmental Services 
ABET BAND UNIT STANDARD TYPE PRE-2009 NQF LEVEL NQF LEVEL CREDITS
Undefined  Regular  Level 5  Level TBA: Pre-2009 was L5 
REGISTRATION STATUS REGISTRATION START DATE REGISTRATION END DATE SAQA DECISION NUMBER
Reregistered  2018-07-01  2023-06-30  SAQA 06120/18 
LAST DATE FOR ENROLMENT LAST DATE FOR ACHIEVEMENT
2024-06-30   2027-06-30  

In all of the tables in this document, both the pre-2009 NQF Level and the NQF Level is shown. In the text (purpose statements, qualification rules, etc), any references to NQF Levels are to the pre-2009 levels unless specifically stated otherwise.  

This unit standard does not replace any other unit standard and is not replaced by any other unit standard. 

PURPOSE OF THE UNIT STANDARD 
This unit standard will be useful for people working as clinically focused, service orientated, independent, registered staff nurses, who are able to render basic care to persons with stable and uncomplicated general health problems, as determined by the appropriate legislative framework.

This unit standard will recognise the essential knowledge and skills required to carry out a comprehensive health assessment focused on activities of living and health behavior of an individual of any age.

People credited with this unit standard are able to:
  • Gather health assessment data.
  • Assess the functional level of a child, adult and/or aged person.
  • Facilitate a developmental assessment process to determine the level of development of a child, adult and/or aged person.
  • Formulate a nursing diagnosis. 

  • LEARNING ASSUMED TO BE IN PLACE AND RECOGNITION OF PRIOR LEARNING 
    The credit calculation is based on the assumption that learners are already competent in terms of the following outcomes or areas of learning when starting to learn towards this unit standard:
  • ID 252098: Use communication skills to establish and maintain supportive relationships.
  • Ethics of confidentiality and informed consent (NQF Level 5). 

  • UNIT STANDARD RANGE 
    Specific range statements are provided in the body of the unit standard where they apply to particular specific outcomes or assessment criteria.

    The following scope and context applies to the whole unit standard:
  • The Nurse functions within the scope of practice of a staff nurse as formulated by the SANC and the Nursing Act.
  • Nurses must be competent to conduct assessments on all three age categories - child, adult and aged person. 

  • Specific Outcomes and Assessment Criteria: 

    SPECIFIC OUTCOME 1 
    Gather health assessment data. 

    ASSESSMENT CRITERIA
     

    ASSESSMENT CRITERION 1 
    The interview is conducted at a level appropriate to the health care user, and in a non-threatening, friendly and open manner. 
    ASSESSMENT CRITERION RANGE 
    Manner includes:
  • Openness; physical level/position; eye contact; appropriate touch; demeanour; courtesy; personal state (relaxed, tense).
     

  • ASSESSMENT CRITERION 2 
    A range of interviewing skills are used to gather all information relevant to the purpose of the assessment, in line with established institutional practice. 
    ASSESSMENT CRITERION RANGE 
    Interviewing skills include:
  • Setting persons at ease; establishing contact; use of questions; opportunities for clarification; reflection of understanding.

    Information includes:
  • Biographical data; history (body systems); current complaint.
     

  • ASSESSMENT CRITERION 3 
    Probing questions are used effectively to gather additional information relevant to the current situation and affected body systems, in order to extend or complete the patient profile. 

    ASSESSMENT CRITERION 4 
    Information is gathered in a logical sequence, and organised for ease of reference. 

    ASSESSMENT CRITERION 5 
    Information gathered is compared to the normal expectations for a patient of that age and gender. Variances from the norm are noted for further reference. 

    ASSESSMENT CRITERION 6 
    Physical and mental assessments and tests conducted are appropriate to the particular context, health care user, presentation of signs and symptoms, and/or the purpose of the assessment. 
    ASSESSMENT CRITERION RANGE 
    Tests include:
  • Physical data (urine; vital signs; movement/mobility; blood; ECG; palpation of pregnant woman; auscultation with fetoscope); mental state examination (physical appearance; thought processes; thinking ability; alertness, responses, awareness, appropriateness, orientation, judgement, insight into situation).
     

  • ASSESSMENT CRITERION 7 
    Different sources of information about the health state of the patient are correlated, and conclusions reached are consistent with the evidence gathered. 

    SPECIFIC OUTCOME 2 
    Assess the functional level of a child, adult and/or aged person. 

    ASSESSMENT CRITERIA
     

    ASSESSMENT CRITERION 1 
    The patient's and/or carers' ability to carry out activities of daily living is accurately determined with respect to the demands of daily living, and the extent to which the illness or condition has affected the functionality of the patient. 
    ASSESSMENT CRITERION RANGE 
    Activities of daily living include:
  • Ability to help themselves; go to work; economic activity; social functioning; normal bodily/biological functioning.
     

  • ASSESSMENT CRITERION 2 
    The assessment confirms information with respect to functionality directly with the patient, and is not dependent on third party information. Particular care is taken in cases where a care giver is present and providing information. 

    ASSESSMENT CRITERION 3 
    Every support is offered to patients in cases where their health status is such that is difficult for them to provide direct information on their functional level. 

    ASSESSMENT CRITERION 4 
    The assessment accurately determines the nature, extent and sustainability of the support available to the patient on a daily basis. Where essential support is absent, this is noted for planning and/or referral purposes. 

    ASSESSMENT CRITERION 5 
    Where interventions are recommended, they are appropriate to the patient's health status, and support and/or improve patient functionality. 

    ASSESSMENT CRITERION 6 
    Where patient functionality or carer support is determined to be inadequate to the requirements of daily living, patients are referred to facilities or health care appropriate to their current and projected health status. 

    SPECIFIC OUTCOME 3 
    Conduct a developmental assessment process to determine the level of development of a child, adult and/or aged person. 

    ASSESSMENT CRITERIA
     

    ASSESSMENT CRITERION 1 
    Instruments and/or approaches selected to determine the level of development in various aspects of functioning, are appropriate to the purpose of the assessment and stage of development. 
    ASSESSMENT CRITERION RANGE 
    Assessments include:
  • Developmental assessment using a variety of instrumentation and approaches.
     

  • ASSESSMENT CRITERION 2 
    Facilitation effectively utilises the different skills and approaches of the professionals within a multi-disciplinary team, and maximises their contribution to the benefit of the patient and the assessment. 

    ASSESSMENT CRITERION 3 
    Facilitation ensures that all stakeholders are provided with an opportunity to contribute in line with their identified role, and in ways that are consistent with a strengths based approach and a needs based understanding of behaviour. 
    ASSESSMENT CRITERION RANGE 
    Facilitation includes:
  • Connecting (professionals, child, family, others); directing discussion (participation, turn taking, tone and the purpose); eliciting feedback and comment; listening skills (feelings, intonation, pain, unspoken, interpretation, linking themes, identify patterns); questioning skills; containment (reflect feelings, containing emotions); summarising (content as well as feelings - in 'plain' language); reframing; identify strengths.
     

  • ASSESSMENT CRITERION 4 
    The pace of the assessment is appropriate to the language level and/or level of understanding of the patient and/or carer/s. 

    ASSESSMENT CRITERION 5 
    Focus is maintained on the patient, and the whole process is managed so that the experience is developmental for all concerned. 

    ASSESSMENT CRITERION 6 
    Facilitation demonstrates cultural competence and proceeds with respect for the privacy and intimate details of all concerned parties. 

    ASSESSMENT CRITERION 7 
    Participation of the patient throughout the assessment is managed in ways that are supportive, and promote active participation within defined parameters. 
    ASSESSMENT CRITERION RANGE 
    Support includes:
  • Recognition of patient; communication (including translation); behaviour management; preparation for issues that may be raised; rehearsal; seating arrangements; guidelines for interaction; choice of venue.

    Parameters include:
  • Professional boundaries; limitations of the patient's condition; limitations of the patient's tolerance.
     

  • SPECIFIC OUTCOME 4 
    Formulate a nursing diagnosis. 

    ASSESSMENT CRITERIA
     

    ASSESSMENT CRITERION 1 
    The interpretation of the assessment data reflects an accurate understanding of the physical and psycho-social dynamics of the health problem/s. Interpretation is in line with own scope of practice and competence. 

    ASSESSMENT CRITERION 2 
    The nursing diagnosis is a logical outflow of the information and analysis of data, and the diagnosis is supported by the assessment data and its interpretation. Interpretation is consistent with generally accepted medical, surgical and mental understanding of conditions and illnesses. 

    ASSESSMENT CRITERION 3 
    Information and interpretation is documented accurately, and in accordance with the requirements of the institution and current legislation and/or regulations. 

    ASSESSMENT CRITERION 4 
    Information gathered and consolidated provides an accurate profile of the patient, the carers and/or support mechanisms, and useful insights into a possible healing process. 

    ASSESSMENT CRITERION 5 
    Information gathered and recorded during the assessment is pertinent to the case at hand, consistent with the assessment approach, and useful for planning to meet developmental needs. 

    ASSESSMENT CRITERION 6 
    The health assessment report meets institutional requirements for approach, language level, and assessment framework. It presents a holistic picture of the patient in context. 


    UNIT STANDARD ACCREDITATION AND MODERATION OPTIONS 
    Accreditation Options:
  • Providers of learning towards this unit standard will need to meet the accreditation requirements of the relevant ETQA.

    Moderation Option:
  • The moderation requirements of the relevant ETQA must be met in order to award credit to learners for this unit standard. 

  • UNIT STANDARD ESSENTIAL EMBEDDED KNOWLEDGE 
    The following essential embedded knowledge will be assessed through assessment of the specific outcomes in terms of the stipulated assessment criteria. Candidates are unlikely to achieve all the specific outcomes, to the standards described in the assessment criteria, without knowledge of the listed embedded knowledge. This means that for the most part, the possession or lack of the knowledge can be directly inferred from the quality of the candidate's performance. Where direct assessment of knowledge is required, assessment criteria have been included in the body of the unit standard.

    The following embedded knowledge is addressed in an integrated way in the unit standard:
  • Concepts of health and illness (mental and physical).
  • Stages of human development.
  • Concepts of "activities of daily living" and "self-care".
  • Understanding of health behaviour models.
  • Understanding of data collection interview.
  • Understanding of health-illness continuum.
  • Understanding of ageing process. 

  • UNIT STANDARD DEVELOPMENTAL OUTCOME 
    N/A 

    UNIT STANDARD LINKAGES 
    N/A 


    Critical Cross-field Outcomes (CCFO): 

    UNIT STANDARD CCFO IDENTIFYING 
    Identify and solve problems and make decisions using critical and creative thinking.
  • Note: Health assessments require problem solving and decision making. 

  • UNIT STANDARD CCFO WORKING 
    Work effectively with others as members of a team, group, organisation or community.
  • Note: Health care provision is team based. 

  • UNIT STANDARD CCFO ORGANISING 
    Organise and manage themselves and their activities responsibly and effectively.
  • Note: Conducting a health assessment requires effective organisation. 

  • UNIT STANDARD CCFO COLLECTING 
    Collect, analyse, organise and critically evaluate information.
  • Note: Core to the standard - gathering information. 

  • UNIT STANDARD CCFO COMMUNICATING 
    Communicate effectively, using visual, mathematical and/or language skills in the modes of oral and/or written presentations.
  • Note: Core to the standard - gathering information. 

  • UNIT STANDARD CCFO SCIENCE 
    Use science and technology effectively and critically showing responsibility towards the environment and health of others.
  • Note: Essential in testing and assessment. 

  • UNIT STANDARD CCFO DEMONSTRATING 
    Demonstrate an understanding of the world as a set of related systems by recognising that problem-solving contexts do not exist in isolation.
  • Note: The body as set of related a systems, affected by external factors. 

  • UNIT STANDARD ASSESSOR CRITERIA 
    N/A 

    REREGISTRATION HISTORY 
    As per the SAQA Board decision/s at that time, this unit standard was Reregistered in 2012; 2015. 

    UNIT STANDARD NOTES 
    Notes to Assessors:

    Assessors should keep the following general principles in mind when designing and conducting assessments against this unit standard:
  • Focus the assessment activities on gathering evidence in terms of the main outcome expressed in the title to ensure assessment is integrated rather than fragmented. Remember we want to declare the person competent in terms of the title. Where assessment at title level is unmanageable and then focuses assessment around each specific outcome, or groups of specific outcomes.
  • Make sure that evidence is gathered across the entire range, wherever it applies. Assessment activities should be as close to the real performance as possible, and where simulations or role-plays are used, there should be supporting evidence to show the candidate is able to perform in the real situation.
  • Do not focus the assessment activities on each assessment criterion. Rather make sure the assessment activities focus on outcomes and are sufficient to enable evidence to be gathered around all the assessment criteria.
  • The assessment criteria provide the specifications against which assessment judgements should be made. In most cases, knowledge can be inferred from the quality of the performances, but in other cases, knowledge and understanding will have to be tested through questioning techniques. Where this is required, there will be assessment criteria to specify the standard required.
  • The task of the assessor is to gather sufficient evidence, of the prescribed type and quality, as specified in this unit standard, that the candidate can achieve the outcomes again and again and again. This means assessors will have to judge how many repeat performances are required before they believe the performance is reproducible.
  • All assessments should be conducted in line with the following well documented principles of assessment: appropriateness, fairness, manageability, integration into work or learning, validity, direct, authentic, sufficient, systematic, open and consistent.

    The following particular issues should be taken into consideration when assessing against this unit standard:
  • The SANC guidelines are used as a reference for integrated assessment.
  • Formative Assessment: A variety of assessment strategies and/or approaches integrating theory and practice must be used. These could be tests, assignments, projects, demonstrations or clinical assessments or any other applicable method.
  • Summative: This could take a form of oral, written and/or practical assessments as agreed to with the relevant ETQA.
  • Nurses must be assessed as competent to conduct assessments of children, adults and aged persons before credits are awarded.

    Definition of Terms:

    Terms have been clarified as far as possible through the use of range statements. Further clarification of terms is provided as follows:
  • The terms "patient" and "health care user" are used interchangeably in this unit standard. The term patient is used internationally, and the term health care user is used in the Nursing Act 33 of 2005, as well as the National Health Act 61 of 2003. 

  • QUALIFICATIONS UTILISING THIS UNIT STANDARD: 
      ID QUALIFICATION TITLE PRE-2009 NQF LEVEL NQF LEVEL STATUS END DATE PRIMARY OR DELEGATED QA FUNCTIONARY
    Core  59236   National Diploma: Nursing  Level 5  NQF Level 05  Passed the End Date -
    Status was "Reregistered" 
    2020-07-30  As per Learning Programmes recorded against this Qual 
    Fundamental  59257   Bachelor of Nursing  Level 7  NQF Level 08  Reregistered  2023-06-30  As per Learning Programmes recorded against this Qual 


    PROVIDERS CURRENTLY ACCREDITED TO OFFER THIS UNIT STANDARD: 
    This information shows the current accreditations (i.e. those not past their accreditation end dates), and is the most complete record available to SAQA as of today. Some Primary or Delegated Quality Assurance Functionaries have a lag in their recording systems for provider accreditation, in turn leading to a lag in notifying SAQA of all the providers that they have accredited to offer qualifications and unit standards, as well as any extensions to accreditation end dates. The relevant Primary or Delegated Quality Assurance Functionary should be notified if a record appears to be missing from here.
     
    NONE 



    All qualifications and part qualifications registered on the National Qualifications Framework are public property. Thus the only payment that can be made for them is for service and reproduction. It is illegal to sell this material for profit. If the material is reproduced or quoted, the South African Qualifications Authority (SAQA) should be acknowledged as the source.