Curriculum standards

Entrustable Professional Activities

LG5: Clinical assessment and management

Learning Goal 5

Clinical reasoning in diagnosis and management

Clinically assess and provide management to sick and healthy neonates

This activity requires the ability to:

  • identify and access sources of relevant information about patients
  • obtain patient histories
  • examine patients
  • synthesise findings to develop provisional and differential diagnoses
  • discuss findings with patients
  • formulate management plans
  • present findings to other health professionals

Professional practice framework domain

Medical expertise

confident
Ready to perform without supervision

Expected behaviours of a trainee who can routinely perform this activity without needing supervision

The trainee will:

  • elicit accurate, systematic, and problem-focused medical histories, considering physical, psychosocial, and risk factors
  • perform systematic physical examinations to establish the nature and extent of problems in sick and healthy neonates
  • recognise the significance of maternal and fetal conditions on the health and developmental outcomes of the neonate
  • assess the severity of problems, the likelihood of complications, and the nature and extent of potential clinical outcomes
  • assess if patients’ current location (such as a regional unit, postnatal ward, or perinatal centre) can provide the appropriate level of care or if the patient needs to be transferred to another location
  • synthesise findings on histories and physical examinations to develop provisional and differential diagnoses
  • formulate patient-centred management plans
  • use new technologies, including artificial intelligence (AI), that support clinical practice for safety and efficacy

direction
Requires some supervision

Possible behaviours of a trainee who needs some supervision to perform this activity

The trainee may:

  • elicit limited patient-centred histories
  • perform targeted physical examinations
  • recognise and correctly interpret abnormal findings
  • synthesise pertinent information to direct clinical encounters and diagnostic categories
  • develop appropriate management plans

Communication

confident
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 and their family or carers to enable them to make fully informed decisions
  • communicate clearly, effectively, respectfully, and promptly with other health professionals involved in patients’ care
  • use technology, such as AI, in development of written communication, where appropriate

direction
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’ dispositions to colleagues, including senior clinicians

Quality and safety

confident
Ready to perform without supervision

Expected behaviours of a trainee who can routinely perform this activity without needing supervision

The trainee will:

  • provide accurate, clear, complete, and timely documentation of clinical information in patients’ medical records
  • demonstrate safety skills, including infection control, adverse event reporting, and effective clinical handover
  • obtain informed consent before undertaking any investigation or providing treatment (except in an emergency)
  • inform patients of the material risks associated with any part of proposed management plans
  • recognise the value and pitfalls of using evolving technologies, such as AI, to aid clinical decision making

direction
Requires some supervision

Possible behaviours of a trainee who needs some supervision to perform this activity

The trainee may:

  • perform hand hygiene, and take infection control precautions at appropriate moments

Teaching and learning

confident
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 and learn, appropriate to the setting

Research

confident
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, collate, analyse, interpret, and evaluate information relevant to the research subject

direction
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
  • recognise the limitations of evidence and the challenges of applying research in clinical practice

Cultural safety

confident
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 and 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 recognise the potential limitations of each
  • acknowledge patients’ beliefs and values, and how these might impact on their health

direction
Requires some supervision

Possible behaviours of a trainee who needs some supervision to perform this activity

The trainee may:

  • demonstrate respect for patients’ cultures, and attentiveness to social determinants of health
  • appropriately access interpretive or culturally focused services
  • recognise cultural sensitivities

Ethics and professional behaviour

confident
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 and colleagues
  • 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
  • demonstrate awareness of medicolegal and social issues around child protection
  • identify and manage families at high psychosocial risk, including taking full drug and alcohol histories
  • identify strategies for the safe discharge and community support of families at high psychosocial risk
  • identify ethical challenges with implementation of evolving technologies, including AI, into clinical practice

direction
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

confident
Ready to perform without supervision

Expected behaviours of a trainee who can routinely perform this activity without needing supervision

The trainee will:

  • use a holistic approach to health, considering comorbidity, risk, and uncertainty
  • use the best available evidence for the most effective therapies and interventions to ensure quality care
  • apply knowledge and experience to identify patients’ problems, making logical, rational decisions, and acting to achieve positive outcomes for patients
  • use technology safely and ethically for aiding decisions, and where appropriate

direction
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

confident
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
  • demonstrate awareness of colleagues in difficulty, and work within the appropriate structural systems to support them while maintaining patients’ safety

direction
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

confident
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 the optimal cost-effective patient care to allow maximum benefit from the available resources
  • demonstrate a collaborative approach to developing protocols, such as for the prevention and management of perinatal sepsis, hand washing, and infection control measures in clinical practice
  • advocate and support infection control policies and practices in the neonatal unit

direction
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