Entrustable Professional Activities

LG5: Clinical assessment, investigation and management

Learning Goal 5

Clinical assessment, investigation, and management

Clinically assess, investigate, and manage the ongoing care of workers/patients

This activity requires the ability to:

  • identify and access sources of relevant information about workers/patients
  • take workers’/patients’ histories, including occupational and environmental exposure histories
  • examine workers/patients
  • synthesise findings to develop provisional and differential diagnoses
  • discuss findings with workers/patients, their families and/or carers, and employers, with appropriate consent and consideration of privacy
  • undertake management in line with medical practice, guidelines, and recommendations
  • share findings with other health professionals and relevant parties
  • determine fitness to work
  • consider causative factors
  • generate multidisciplinary biopsychosocial management plans
  • develop return to work programs
  • formulate comprehensive evidence-based written reports that articulate the above components of care

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, organised, and problem-focused medical histories, considering occupationally and environmentally related risk factors
  • elicit suitable mental health histories that include psychosocial workplace hazards that increase the risk of physical and psychological conditions in the workplace
  • discuss non-work-related mental health conditions, physical conditions, psychosocial and other factors that may affect work
  • perform full and appropriate occupational histories and examinations to establish the nature and extent of problems
  • perform mental state examinations where required
  • synthesise and interpret findings from histories and examinations to devise the most likely provisional diagnoses via reasonable differential diagnoses
  • identify and perform suitable investigations
  • develop an evidence-based model for disease and injury causation
  • assess the severity of problems, the likelihood of complications, and clinical outcomes
  • develop management plans based on relevant guidelines, workplace information, and the workers’/patients’ circumstances
  • develop, implement, assess, and evaluate health surveillance programs
  • identify the workers’/patients’ disorders requiring management
  • consider age, chronic disease status, social supports, worker/patient preference, and lifestyle, organisational, and personal factors in the development of management plans 
  • consider non-pharmacologic therapies
  • plan for follow-up and monitoring

direction
Requires some supervision

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

The trainee may:

  • elicit worker/patient-centred histories, considering psychosocial factors
  • perform accurate physical examinations
  • perform statutory health surveillance
  • recognise and correctly interpret abnormal findings
  • synthesise pertinent information to direct clinical encounters and diagnostic categories
  • demonstrate an understanding of disease causation
  • develop appropriate management plans
  • identify and manage adverse events
  • describe and assign causation of injuries and diseases to workplace exposures and events using evidence-based medicine

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 workers’/patients’ concerns seriously, giving them adequate opportunity to ask questions
  • provide information to workers/patients and their family and/or carers to enable them to make fully informed decisions from various diagnostic, management, and therapeutic options
  • provide information to co-workers and/or workplaces as medically and ethically appropriate and legally required
  • communicate clearly, effectively, respectfully, and promptly with other health professionals involved in workers’/patients’ care
  • demonstrate suitable report writing and presentation skills
  • discuss and evaluate the risks, benefits, and rationale of treatment options, making decisions in partnership with workers/patients
  • educate workers/patients and employers about the benefits of good work and appropriate safe return to work
  • write clear and legible management plans in plain language
  • communicate with workers/patients, families and/or carers about the benefits and risks of proposed therapies
  • ensure workers/patients understand management plans by repeating back pertinent information, such as the time frame, tasks, and when to return for review
  • explore workers’/patients’ understanding of and preferences for non-pharmacological and pharmacological management
  • ensure appropriate information is provided at all steps of the management pathway

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 workers’/patients' situations to colleagues, including senior clinicians
  • discuss and explain the rationale for treatment options with workers/patients, families and/or carers
  • explain the benefits and burdens of therapies, considering workers’/patients’ individual circumstances
  • write clear and legible management plans
  • seek further advice from experienced clinicians or pharmacists when appropriate
  • provide instructions on medication administration effects and side effects

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 and adverse event reporting
  • recognise and effectively deal with aggressive and violent worker/patient behaviours
  • obtain informed consent before undertaking any investigations or providing treatment (except in an emergencies)
  • ensure workers/patients are informed of the material risks associated with any part of proposed management plans
  • review as appropriate to monitor progress and adjust management

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 precaution against assaults from confused or agitated workers/patients, ensuring appropriate care of workers/patients
  • document history and physical examination findings, and synthesise with clarity and completeness

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 workers/patients in teaching activities
  • turn clinical activities into an opportunity to teach, appropriate to the setting
  • check workers/patients understand management plans, including adherence issues

direction
Requires some supervision

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

The trainee may:

  • set unclear goals and objectives for self-learning
  • self-reflect infrequently
  • deliver teaching considering learners’ level of training
  • undertake continuing professional development to maintain currency with prescribing guidelines
  • reflect on prescribing, and seek feedback from a supervisor

Research

confident
Ready to perform without supervision

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

The trainee will:

  • demonstrate the ability to search for, find, compile, analyse, interpret, and evaluate information relevant to the research subject
  • critically appraise research material to consider new management that may lead to improved worker/patient outcomes
  • use sources of independent information about management to ensure accurate summaries of the available evidence on management options

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 understanding of the limitations of evidence and the challenges of applying research in daily practice
  • make therapeutic decisions according to the best evidence
  • recognise where evidence is limited, compromised, or subject to bias or conflict of interest

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 worker/patient education materials, and culturally safe language
  • demonstrate culturally safe communication and care for Aboriginal and Torres Strait Islander and Māori peoples, and members of other cultural groups
  • use professional interpreters, health advocates, or family or community members to assist in communication with workers/patients, and understand the potential limitations of each
  • acknowledge workers’/patients’ beliefs and values, and how these might affect health
  • offer workers/patients effective choices based on their expectations of treatment, health beliefs, and cost
  • interpret and explain information to workers/patients at the appropriate level of their health literacy

direction
Requires some supervision

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

The trainee may:

  • display respect for workers’/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
  • appreciate workers/patients cultural and religious backgrounds, attitudes, and beliefs, and how these might influence the acceptability of pharmacological and non-pharmacological management approaches

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 workers/patients
  • hold information about workers/patients in confidence, unless the release of information is required by law or public interest
  • assess workers’/patients’ capacity for decision making, involving a proxy decision maker appropriately
  • provide information to workers/patients about their proposed management plan that may include:
    • details (hours / tasks)
    • timeframe
    • timing of periodic review
  • demonstrate understanding of the ethical implications of industry-funded research and marketing

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 workers’/patients’ decision-making capacity
  • identify workers’/patients’ preferences regarding management and the role of families in decision making
  • not advance personal interest or professional agendas at the expense of workers/patients or social welfare
  • consider the efficacy of medicines in treating illnesses, including the relative merits of different non-pharmacological and pharmacological approaches
  • follow regulatory and legal requirements and limitations regarding prescribing

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 workers’/patients’ problems, making logical, rational decisions, and acting to achieve positive outcomes for workers/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
  • use a systematic and worker/patient-centred approach to determine management plans

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
  • consider the following factors for all proposed management options:
    • funding and regulatory considerations
    • organisational culture
    • organisational resources
    • sociocultural supports
    • worker/patient characteristics and preferences

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, including non-health professionals to achieve the best health outcome for workers/patients
  • demonstrate awareness of colleagues in difficulty, and work within the appropriate structural systems to support them while maintaining worker/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:

  • participate in health promotion, disease prevention and control, screening, and reporting notifiable diseases
  • aim to achieve optimal cost-effective worker/patient care to allow maximum benefit from available resources
  • choose management approaches with consideration of comparative efficacy and cost effectiveness
  • development management plans for individual workers/patients considering available supports, current management, history, and preferences, ensuring that resources are used wisely for the benefit of workers/patients

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 workers’/patients’ care
  • identify and access relevant community resources to support workers’/patients’ care