Chapter 1 – Introduction to Health Assessment
Any health assessment you perform must fall within your nursing scope of practice and be informed by the appropriate nursing College or association practice standards. In Ontario, the College of Nurses of Ontario (CNO) is the legal governing body for nurses, so as a nurse, you must perform health assessment within the CNO legislated scope of practice, the practice standards, and also based on your individual level of competence (i.e., knowledge and expert practice to perform an action).
It is important to be aware of controlled acts, which are activities that are considered harmful if performed by someone who is unqualified as per the Regulated Health Professions Act (RHPA) (CNO, 2020a). As per the RHPA, a controlled act must only be performed with an order or when permitted by specific regulations and you must be competent to perform the skill/procedure (CNO, 2020a). For example, it is within your scope of practice to perform health assessments that move “below the dermis or mucous membrane” or involve putting your finger/hands or an instrument beyond “the external ear canal,” regions where the nasal passages narrow, the larynx, urethra, labia majora, anal verge, or “into an artificial opening in the body” as long as there is an order from a physician AND you are competent to perform this skill/procedure (CNO, 2020a).
As a nursing student, you are not yet a registered nurse. Therefore, with guidance from your supervisor/preceptor/clinical instructor, you must assess your competence to perform the controlled act and do so safely. If the decision is that you do not have the knowledge and skill to perform the controlled act, you may observe and use this as a learning opportunity.
Keep in mind that many controlled acts are related to interventions (e.g., treatment procedures) that you perform as a nurse, and some controlled acts relate to assessment techniques (e.g., performing an invasive technique).
When you perform an assessment, it is important to inform the client what you are assessing and typically share some of the findings that are within your scope of practice (e.g., I noticed inflammation around your ear drum). However, you are not permitted to communicate a diagnosis about what is causing the inflammation around the ear drum. Communicating a diagnosis is not permitted because this is considered a controlled act and outside of the registered nursing specific controlled acts (CNO, 2020b). Communicating a diagnosis is done by certain regulated health professionals such as a physician or nurse practitioner. However, you may be expected to communicate a diagnosis if you are delegated to do so by a physician or nurse practitioner and you have the knowledge to do so.
In performing any health assessment, you are also required to adhere to the CNO practice standards. Common practice standards that apply to health assessment include information related to consent and permission to touch, privacy and confidentiality, therapeutic nurse-client relationship, and documentation. Many of these CNO documents are based on health laws. It is important to recall that nurses are legally obligated to document their health assessment findings as per the CNO Documentation practice standard, as shown in Documentation in Nursing: 1st Canadian edition.
College of Nurses of Ontario (2020a). Legislation and regulation: An introduction to the Nursing Act, 1991. https://www.cno.org/globalassets/docs/prac/41064_fsnursingact.pdf
College of Nurses of Ontario (2020b). Legislation and regulation RHPA: Scope of practice, controlled acts model. https://www.cno.org/globalassets/docs/policy/41052_rhpascope.pdf