Curriculum standards
Entrustable Professional Activities
LG5: Clinical assessment and management
Clinical assessment and management
Clinically assess and manage the ongoing care of patients
This activity requires the ability to:
- identify and access sources of relevant information about patients
- obtain patient histories, including comprehensive medication histories
- examine patients
- synthesise findings to develop provisional and differential diagnoses
- discuss findings with patients
- generate management plans
- present findings to other health professionals
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:
- elicit accurate, organised, and problem-focused medical histories, considering risk factors, including medication adherence and physical and psychosocial components
- perform full physical examinations to establish the nature and extent of problems, including toxicities and overdoses
- demonstrate initial assessment and management of suicide risk, mental capacity, and mental health status in poisoned patients
- synthesise and interpret findings from histories, examinations, and investigations, integrate data from wearables, and devise the most likely diagnoses for clinical management
- assess the severity of problems, likelihood of complications, and clinical outcomes
- develop management plans based on relevant guidelines, and consider the balance of benefit and harm by taking patients’ personal sets of circumstances into account, including substance use or dependence
- produce expert clinical / scientific reports
Requires some supervision
Possible behaviours of a trainee who needs some supervision to perform this activity
The trainee may:
- take patient-centred histories, considering psychosocial factors
- perform accurate physical examinations
- recognise and correctly interpret abnormal findings
- synthesise pertinent information to direct the clinical encounter and diagnostic categories
- develop appropriate management plans
Communication
Ready to perform without supervision
Expected behaviours of a trainee who can routinely perform this activity without needing supervision
The trainee will:
- communicate openly, listen, and take patients’ concerns seriously, giving them adequate opportunity to ask questions
- provide information to patients to enable them to make fully informed decisions from various diagnostic, therapeutic, and management options
- communicate clearly, effectively, respectfully, and promptly with other health professionals involved in patients’ care
- work in partnership with patients to construct medicine optimisation plans to address complex prescribing needs
- communicate complex prescribing issues and proposed management choices to patients and their healthcare providers
Requires some supervision
Possible behaviours of a trainee who needs some supervision to perform this activity
The trainee may:
- anticipate, read, and respond to verbal and nonverbal cues
- demonstrate active listening skills
- communicate patients’ situations to colleagues, including senior clinicians
Quality and safety
Ready to perform without supervision
Expected behaviours of a trainee who can routinely perform this activity without needing supervision
The trainee will:
- demonstrate safety skills, including infection control and pharmacovigilance activities, including adverse event reporting and effective clinical handover
- recognise and effectively deal with aggressive and violent patient behaviours through appropriate training
- obtain informed consent before undertaking any investigation or providing treatment (except in an emergency)
- ensure patients are informed of the material risks associated with any part of proposed investigations or management plans
Requires some supervision
Possible behaviours of a trainee who needs some supervision to perform this activity
The trainee may:
- take precaution against assaults from confused or agitated patients, ensuring appropriate care of patients
- document history and physical examination findings, and synthesise with clarity and completeness
Teaching and learning
Ready to perform without supervision
Expected behaviours of a trainee who can routinely perform this activity without needing supervision
The trainee will:
- set defined objectives for clinical teaching encounters, and solicit feedback on mutually agreed goals
- regularly reflect upon and self-evaluate professional development
- obtain informed consent before involving patients in teaching activities
- turn clinical activities into an opportunity to teach, appropriate to the setting
- provide poisons advice for common poisons exposures
- communicate and teach pharmacokinetic principles to other staff, and apply to specific patients
- participate in ongoing education about new drugs on the market, updates in pharmacotherapy guidelines, and emerging evidence in drug therapy
- use resources for learning about global differences in drug availability and regulatory considerations
Requires some supervision
Possible behaviours of a trainee who needs some supervision to perform this activity
The trainee may:
- deliver teaching considering learners’ level of training
Research
Ready to perform without supervision
Expected behaviours of a trainee who can routinely perform this activity without needing supervision
The trainee will:
- search for, find, compile, analyse, interpret, and evaluate information relevant to the research subject
- appropriately contribute to drug evaluation committees
- write submissions to ethics committees
- stay informed and up to date on advances in research and best practice clinical care
- participate in conduct of randomised control trials
Requires some supervision
Possible behaviours of a trainee who needs some supervision to perform this activity
The trainee may:
- refer to guidelines and medical literature to assist in clinical assessments when required
- demonstrate an understanding of the limitations of evidence and the challenges of applying research in daily practice
- explain the safety requirements of research subjects
- retrieve and interpret the literature on more complex issues
Cultural safety
Ready to perform without supervision
Expected behaviours of a trainee who can routinely perform this activity without needing supervision
The trainee will:
- use plain-language patient education materials, and demonstrate cultural and linguistic sensitivity
- demonstrate effective and culturally safe communication and care for Aboriginal and Torres Strait Islander peoples, Māori, and members of other cultural groups
- use a professional interpreter, health advocate, or a family or community member to assist in communication with patients, and understand the potential limitations of each
- acknowledge patients’ beliefs and values, and how these might impact on health
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 professional values, including compassion, empathy, respect for diversity, integrity, honesty, and partnership to all patients
- hold information about patients in confidence, unless the release of information is required by law or public interest
- assess patients’ capacity for decision making, involving a proxy decision maker appropriately
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
- not advance personal interest or professional agendas at the expense of patient or social welfare
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 identify patients’ problems, making logical, rational decisions, and acting to achieve positive outcomes for patients
- use a holistic approach to health, considering comorbidity, uncertainty, and risk
- use the best available evidence for the most effective therapies and interventions to ensure quality care
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
- 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:
- work effectively as a member of multidisciplinary teams to achieve the best health outcomes for patients, including with laboratory scientists
- demonstrate awareness of colleagues in difficulty, and work within the appropriate structural systems to support them while maintaining patient safety
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 healthcare 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:
- participate in health promotion, disease prevention and control, screening, and reporting notifiable diseases
- aim to achieve optimal cost-effective patient care to allow maximum benefit from the available resources
- aim to incorporate environmentally sustainable service delivery
- advocate for patients when there are escalating concerns for their deteriorating condition
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 patients’ care