Entrustable Professional Activities

LG5: Clinical assessment and management

Learning Goal 5

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
  • examine patients
  • synthesise findings to develop provisional and differential diagnoses
  • discuss findings with patients, families, and/or carers
  • generate 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:

  • synthesise and interpret findings from histories and examinations to devise the most likely provisional diagnoses via reasonable differential diagnoses
  • perform relevant physical examinations to establish the nature and extent of problems, including immune compromise
  • recognise and correctly interpret abnormal findings
  • request appropriate diagnostic investigations, considering patients’ history and examination
  • assess the severity of problems, the likelihood of complications, and clinical outcomes
  • develop management plans based on relevant guidelines and priority of treatment
  • consider target empiric therapy towards expected pathogens and local sensitivity patterns
  • determine need for prophylaxis following exposure to communicable disease or potential exposure to blood-borne viruses

direction
Requires some supervision

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

The trainee may:

  • 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 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
  • incorporate appropriate LGBTQIA+ safe language, including gender affirming language

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

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 in an emergency)
  • ensure patients are informed of any risks and/or side effects associated with any part of proposed management plans

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, appropriate to the setting
  • recognise advancements in both scientific and managerial fields that could impact the provision of diagnostic microbiology services
  • practice and teach the principles of diagnostic stewardship, including selecting investigations and interventions that will minimise the number of invasive procedures patients require

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

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 research for evidence for informing best clinical practice
  • appraise existing and new literature critically
  • appraise new interventions, chemotherapeutic agents, and devices critically

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 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:

  • conduct a culturally appropriate and holistic consultation for patients of all ethnic backgrounds, particularly Aboriginal and Torres Strait Islander peoples and Māori

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
  • be cognisant of at least the most prevalent cultures in society, and display 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’ capacity for decision making, involving a proxy decision maker appropriately

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

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, 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
  • consider cost-effectiveness of therapeutic methods when planning and executing treatment 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

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 patient safety
  • liaise effectively with other health care providers and non-clinicians, including administrators, diagnostic service providers, and public health officials

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

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