Entrustable Professional Activities

LG5: Clinical assessment and management

Learning Goal 5

Clinical assessment and management

Clinically assess and manage the ongoing care of patients across multiple settings

This activity requires the ability to:

  • identify and access sources of relevant information about patients across the range of ages, from birth to young people, in inpatient and outpatient tertiary hospitals, community settings, metropolitan and outreach, as well as telehealth methods
  • obtain patient histories
  • examine patients
  • synthesise findings to develop provisional and differential diagnoses
  • generate a management plan (including selecting, organising, undertaking, and interpreting relevant investigations)
  • discuss findings with patients, families and/or carers
  • 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 an accurate, organised, and problem-focused medical history, considering physical, psychosocial, and risk factors
  • perform a full physical examination to establish the nature and extent of problems
  • synthesise and interpret findings from the history and examination to devise the most likely provisional diagnoses via reasonable differential diagnoses, including common and uncommon presentations, acute and chronic / complex conditions
  • assess the severity of problems, the likelihood of complications, and clinical outcomes
  • develop evidence-based management plans, and consider the balance of benefit and harm by taking patients’ personal circumstances into account
  • decide on the most appropriate investigations based on available evidence, minimising unnecessary and potentially harmful investigations where possible
  • use the most appropriate methods to monitor chronic respiratory disease longitudinally
  • oversee the perioperative care of patients having surgical procedures / interventions (e.g., bronchoscopy, insertion and management of pleural drains, insertion and management of IV access)
  • manage patients where there are concerns for child maltreatment (in conjunction with other relevant agencies)

direction
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

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 respond to patients, parents and carers’ concerns seriously, and give them adequate opportunity to ask questions
  • provide information to patients, family, or carers to enable them to make informed decisions from various diagnostic, therapeutic, and management options
  • communicate clearly, effectively, respectfully, and promptly with other health professionals involved in patients’ care
  • communicate sensitively regarding diagnoses and management plans, such as genetic family disorders
  • prepare timely and accurate communication in the form of letters and reports to disseminate elevant medical information to children and families, other health professionals, and other relevant agencies

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’ situations to colleagues, including senior clinicians
  • accurately and thoroughly document clinical histories, examinations, investigations, impressions, and management plans in medical records

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:

  • demonstrate safety skills including infection control, 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 when not feasible (e.g., in some emergency / lifesaving situations)

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
  • take precautions against assaults from agitated patients, and ensure appropriate care of patients
  • document history and physical examination findings, and synthesise with clarity and completeness
  • ensure that patients are informed of the potential risks associated with any part of proposed management plans

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 and self-evaluate professional development

direction
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
  • where appropriate, obtain informed consent before turning clinical activities into teaching opportunities

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, compile, analyse, interpret, and evaluate information relevant to the research subject / clinical question

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
  • demonstrate an understanding of the limitations of the evidence and the challenges of applying research in daily 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:

  • acknowledge patients’ beliefs and values, and how these might impact on health
  • demonstrate effective and culturally safe communication and care for Aboriginal and Torres Strait Islander and Māori peoples, and members of other cultural groups
  • use health information resources that are culturally safe

direction
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

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
  • hold information about patients in confidence, unless the release of information is required by law or public interest
  • assess patients (including young people’s) and/or carers’ capacity for decision making, and involve a proxy decision maker when appropriate

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:

  • apply knowledge and experience to identify patients’ problems, make logical and rational decisions, and act to achieve optimal patient outcomes
  • consider comorbidity, uncertainty, and risk when making decisions about patient care
  • use the best available evidence for the most appropriate therapies and interventions to ensure quality care

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
  • determine the need for referrals

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:

  • present and discuss complicated patients’ cases with local medical and surgical teams and other members of the multidisciplinary team to determine clinical management
  • work effectively as a member of multidisciplinary teams to achieve patients’ best health outcomes
  • demonstrate awareness of colleagues in difficulty, and work within the appropriate structural systems to support them while maintaining patient 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 health care 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:

  • demonstrate appropriate utilisation of local, regional, and national health services and systems
  • participate in health promotion, disease prevention and control, screening, and reporting of notifiable diseases
  • evaluate the cost versus benefit of investigations
  • support and utilise innovations to ensure the delivery of equitable and quality health care, such as telehealth digitally integrated support services
  • participate in health promotion and primary prevention activities and strategies to improve lung health in communities

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 health system relevant to patients’ care
  • identify and access relevant community resources to support patient care