Curriculum standards
Entrustable Professional Activities
LG5: Clinical assessment
Clinical assessment
Clinically assess paediatric patients across multiple settings
This activity requires the ability to:
- identify and access sources of relevant information about patients
- perform expert and efficient assessments of paediatric patients across the age range from birth to young adulthood, in inpatient and outpatient settings
- select, organise, undertake, and interpret relevant investigations
- synthesise findings to develop provisional and differential diagnoses
- consider the comfort and safety of the child, and the values and beliefs of the family or carers
Professional practice framework domain
Medical expertise
Ready to perform without supervision
Expected behaviours of a trainee who can routinely perform this activity without needing supervision
The trainee will:
- assess paediatric patients’ physical and psychological symptoms and signs
- assess common and uncommon paediatric and adolescent inpatient presentations
- assess common and uncommon paediatric and adolescent outpatient presentations
- assess paediatric and adolescent patients with complex, multisystem, and/or chronic diseases
- assess healthy newborns and common neonatal presentations
- assess common developmental paediatric presentations
- assess common paediatric and adolescent mental health presentations
- identify and assess children presenting with signs or symptoms of child maltreatment
- choose evidence-based investigations or assessment tools, and frame them as an adjunct to comprehensive clinical assessments
- minimise unnecessary, potentially harmful, and/or painful investigations where possible
- recognise and appropriately interpret abnormal findings, considering patients’ circumstances
- synthesise and interpret findings from the history, examination, and investigations to devise the most likely provisional diagnoses via reasonable differential diagnoses
- assess the severity of problems, the likelihood of complications, and clinical outcomes
Requires some supervision
Possible behaviours of a trainee who needs some supervision to perform this activity
The trainee may:
- record patient-centred histories, considering psychosocial factors
- perform accurate physical examinations
- provide rationale for investigations
- recognise and correctly interpret abnormal findings
- synthesise pertinent information to direct the clinical encounter and diagnostic categories
Communication
Ready to perform without supervision
Expected behaviours of a trainee who can routinely perform this activity without needing supervision
The trainee will:
- listen and respond to patients’ concerns
- document clinical history, examination, investigations, impressions, and management plans in medical records
- prepare timely and accurate communication in the form of letters and reports to disseminate relevant medical information to patients, other health professionals, and other relevant agencies
Requires some supervision
Possible behaviours of a trainee who needs some supervision to perform this activity
The trainee may:
- communicate appropriately with patients during assessments
Cultural safety
Ready to perform without supervision
Expected behaviours of a trainee who can routinely perform this activity without needing supervision
The trainee will:
- demonstrate effective and culturally safe communication and care for Māori and Aboriginal and Torres Strait Islander peoples
- effectively communicate with members of other cultural groups by meeting patients’ specific language, cultural, and communication needs
- enquire, acknowledge, and reflect on patients’ beliefs and values, and how these might impact on health
- use qualified language interpreters or cultural interpreters where appropriate
Requires some supervision
Possible behaviours of a trainee who needs some supervision to perform this activity
The trainee may:
- display respect for patients’ cultures, and attentiveness to social determinants of health
- display an understanding of at least the most prevalent cultures in society, and an appreciation of their sensitivities
- appropriately access interpretive or culturally focused services
Ethics and professional behaviour
Ready to perform without supervision
Expected behaviours of a trainee who can routinely perform this activity without needing supervision
The trainee will:
- demonstrate and advocate for consideration of the comfort of patients by minimising distress and harm caused by medical assessments
- hold information about patients in confidence, unless the release of information is required by law, under information sharing guidance, or public interest
- assess patients’ capacity for decision making and providing consent for medical procedures
- demonstrate an awareness of complex issues related to genetic information obtained from investigations, and subsequent disclosure of such information
- demonstrate an awareness of complex issues related to documentation of sensitive information gathered in clinical encounters, and subsequent sharing of such information
Requires some supervision
Possible behaviours of a trainee who needs some supervision to perform this activity
The trainee may:
- demonstrate professional conduct, honesty, and integrity
- consider patients’ decision-making capacity
- identify patients’ preferences regarding management and the role of families in decision making
- prioritise patient and social welfare over own personal interest and professional agenda
Judgement and decision making
Ready to perform without supervision
Expected behaviours of a trainee who can routinely perform this activity without needing supervision
The trainee will:
- apply knowledge and experience to assess patients, making logical, rational decisions
- evaluate the costs, benefits, and potential risks of each investigation in clinical situations
- use a holistic approach to health, considering comorbidity, uncertainty, and risk
- use the best available evidence to determine the most appropriate investigations, including not performing unnecessary investigations
- determine the need for referral to subspecialists
- make appropriate decisions in regard to referring or transferring patients to other services for further assessment, including regional and remote patients
- make appropriate decisions in regard to reporting suspected child maltreatment to statutory child protection agencies
- use appropriate guidelines, evidence sources, and decision support tools
- consider possible sources of cognitive bias
Requires some supervision
Possible behaviours of a trainee who needs some supervision to perform this activity
The trainee may:
- demonstrate clinical reasoning by gathering focused information relevant to patients’ care
- choose the most appropriate investigation for clinical scenarios, in discussion with patients
- recognise personal limitations, and seek help in an appropriate way when required
Leadership, management, and teamwork
Ready to perform without supervision
Expected behaviours of a trainee who can routinely perform this activity without needing supervision
The trainee will:
- ensure results are checked in a timely manner, taking responsibility for following up results
- collaborate with other health professionals to achieve accurate and thorough assessments of patients
Requires some supervision
Possible behaviours of a trainee who needs some supervision to perform this activity
The trainee may:
- share relevant information with members of the health care team
Health policy, systems, and advocacy
Ready to perform without supervision
Expected behaviours of a trainee who can routinely perform this activity without needing supervision
The trainee will:
- aim to achieve the optimal cost-effective patient care, to allow maximum benefit from the available resources
- support systems to improve access to health care
Requires some supervision
Possible behaviours of a trainee who needs some supervision to perform this activity
The trainee may:
- identify and navigate components of the healthcare system relevant to patients’ care
- identify and access relevant community resources to support patient care