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 patients’ histories
- examine patients
- perform appropriate standardised assessments, such as:
- American Spinal Injury Association (ASIA) Impairment scale (AIS)
- Functional Independence Measure for Children (WeeFIM)
- manual muscle testing
- musculoskeletal assessment, including goniometer joint ranges
- post-traumatic amnesia testing
- standardised hypertonicity scales
- Westmead post-traumatic amnesia (PTA) testing
- synthesise findings to develop diagnoses and identify impairments, activity limitations, and participation restrictions
- discuss findings and goals with patients, families, and/or carers
- generate multidisciplinary management plans
- discuss findings and plan with other professionals, such as allied health clinicians, general practitioners, and school staff
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 and developmental histories, considering physical, psychosocial, and risk factors
- perform full physical examinations to establish the nature and extent of problems
- synthesise and interpret findings from histories and examinations to devise the most likely provisional diagnoses, impairments, activity limitations, and participation restrictions
- assess the severity of problems, the likelihood of complications, and impact on function and clinical outcomes
- develop goal-directed multidisciplinary management plans based on relevant guidelines, considering the harm / benefit balance by taking patients’ personal circumstances into account
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 goal-directed multidisciplinary 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, families, whānau, and/or carers to enable them to make fully informed decisions from various diagnostic, therapeutic, and management options
- communicate clearly, effectively, respectfully, and promptly with other professionals involved in patients’ care
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 nonspeaking 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, adverse event reporting, and effective clinical handover
- recognise and effectively deal with challenging behaviours
- obtain informed consent before undertaking any investigation or providing treatment (except in an emergency)
- inform patients of the risks associated with any part of the proposed management plans
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
- take precaution against patients displaying challenging behaviours, ensuring appropriate care of patients and safety of staff
- document histories 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
Requires some supervision
Possible behaviours of a trainee who needs some supervision to perform this activity
The trainee may:
- set goals and objectives for self-learning
- self-reflect frequently
- 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
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 and management when required
- recognise the limitations of evidence and the challenges of applying research in daily practice
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 education materials, and demonstrate cultural and linguistical sensitivity
- demonstrate effective and culturally safe communication and care for all groups, including Aboriginal and Torres Strait Islander peoples and Māori
- use a professional interpreter, health advocate, or community member to assist in communication with families
- understand patients’ beliefs and values, and how these might impact on health and function
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 and consent to procedures
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 patients and/or social welfare above personal interest or professional agendas
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 and disability, 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, seeking help when required in an appropriate way
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
- demonstrate awareness of colleagues in difficulty, and work within the appropriate structural systems to support them while maintaining patients’ 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 multidisciplinary 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:
- participate in health promotion, disease prevention and control, screening, and reporting notifiable diseases
- provide optimal cost-effective care to allow maximum benefit from the available resources
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