Entrustable Professional Activities

LG4: Clinical assessment and management

Learning Goal 4

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, including medication histories
  • examine patients
  • synthesise findings to develop provisional and differential diagnoses
  • select, plan, and use evidence-based clinically appropriate investigations
  • interpret the results and outcomes of investigations
  • discuss findings with patients, their families, and/or carers, and generate management plans
  • choose appropriate medicines or procedures based on an understanding of pharmacology and clinical sciences, taking into consideration age, benefits, comorbidities, patient preferences, potential drug interactions, and risks
  • manage chronic and advanced conditions, comorbidities, complications, and disabilities
  • provide continuity of care
  • facilitate patients’ self-management and self-monitoring
  • present findings and collaborate with 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, organised, and problem-focused medical 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 via reasonable differential diagnoses
  • assess the severity of problems, likelihood of complications, and clinical outcomes
  • develop management plans based on relevant guidelines, and consider the balance of benefit and harm by taking patients’ personal sets of circumstances into account
  • assess common dermatological conditions and common skin tumours
  • regularly assess and review care plans for patients with chronic conditions and disabilities, based on short- and long-term clinical and quality of life goals
  • provide documentation on patients’ presentation, management, and progress, including key points of diagnosis and decision making, to inform coordination of care
  • ensure patients contribute to their needs assessments and care planning
  • monitor treatment outcomes, effectiveness, and adverse events
  • choose evidence-based investigations and frame them as an adjunct to comprehensive clinical assessments
  • assess patients’ concerns, and determine the need for specific tests that are likely to result in overall benefit
  • develop plans for investigations, identifying their roles and timing
  • recognise and correctly interpret abnormal findings, considering patients’ specific circumstances, and act accordingly
  • identify patients’ disorders requiring pharmacotherapy
  • consider non-pharmacologic therapies
  • consider age, allergies, chronic disease status, lifestyle factors, potential drug interactions, and patient preference prior to prescribing new medications
  • 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:

  • take patient-centred histories, considering psychosocial factors
  • perform accurate physical examinations
  • recognise and correctly interpret abnormal findings
  • synthesise pertinent information to direct clinical encounters and diagnostic categories
  • assess patients’ knowledge, beliefs, concerns, and daily behaviours related to their chronic condition and/or disability and its management
  • contribute to medical record entries on histories, examinations, and management plans in a way that is accurate and sufficient as a member of multidisciplinary teams
  • 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 from various diagnostic, therapeutic, and management options
  • communicate clearly, effectively, respectfully, and promptly with other health professionals involved in patients’ care
  • encourage patients’ self-management through education to take greater responsibility for their care, and support problem solving
  • encourage patients’ access to self-monitoring devices and assistive technologies
  • communicate with multidisciplinary team members, and involve patients in that dialogue
  • explain to patients the potential benefits, burdens, costs, risks, and side effects of each option, including the option to have no investigations or treatment

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
  • provide healthy lifestyle advice and information to patients on the importance of self-management
  • work in partnership with patients, and motivate them to comply with agreed care plans

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
  • obtain informed consent before undertaking any investigation or providing treatment (except in an emergency)
  • ensure patients are informed of the material risks associated with any part of proposed management plans
  • use innovative models of chronic disease care, using telehealth and digitally integrated support services
  • review medicine use and ensure patients understand safe medication administration to prevent errors
  • support patients’ self-management by balancing between minimising risk and helping patients become more independent
  • participate in quality improvement processes impacting on patients’ abilities to undertake normal activities of daily living
  • identify adverse outcomes that may result from proposed investigations, focusing on patients’ individual 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 precaution against assaults from confused or agitated patients, ensuring appropriate care of patients
  • document histories and physical examination findings, and synthesise with clarity and completeness
  • participate in continuous quality improvement processes and clinical audits on chronic disease management
  • identify activities that may improve patients’ quality of life

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
  • contribute to the development of clinical pathways for chronic diseases management, based on current clinical guidelines
  • educate patients to recognise and monitor their symptoms, and undertake strategies to assist their recovery
  • use appropriate guidelines, evidence sources, and decision support tools

direction
Requires some supervision

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

The trainee may:

  • require assistance with setting goals and objectives for self-learning
  • self-reflect infrequently
  • deliver teaching considering learners’ level of training
  • use clinical practice guidelines for chronic diseases management

Research

confident
Ready to perform without supervision

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

The trainee will:

  • compile, analyse, interpret, and evaluate information relevant to the research subject
  • prepare reviews of literature on patients’ encounters to present at journal club meetings
  • search for and critically appraise evidence to resolve clinical areas of uncertainty
  • provide patients with relevant information if proposed investigations or treatments are part of a research program
  • obtain written consent from patients if the investigation or treatment is part of a research program

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 evidence and the challenges of applying research in daily practice
  • recognise appropriate use of review articles

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, in patients’ primary language when available, and demonstrate cultural and linguistic sensitivity
  • demonstrate effective and culturally safe communication and care for Māori (tangata whenua) and Pacific peoples
  • use professional interpreters, health advocates, or family or community members to assist in communication with patients, and understand the potential limitations of each, including legal and ethical issues
  • acknowledge patients’ beliefs and values, and how these might impact on health
  • recognise and manage unconscious bias
  • incorporate Māori views on health, including the four cornerstones of the Māori health model known as te whare tapa whā

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 values
  • appropriately access interpretive or culturally focused services
  • provide culturally safe chronic disease management

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 awareness of the legal and ethical issues around care of children
  • demonstrate professional conduct and understanding around issues specific to gender diversity
  • demonstrate professional conduct and values, including compassion, empathy, respect for diversity, integrity, honesty, and partnership to all patients
  • share information about patients’ health care, consistent with privacy laws and professional guidelines on confidentiality
  • use consent processes for the release and exchange of health information
  • assess patients’ decision-making capacity, and appropriately identify and use alternative decision makers

direction
Requires some supervision

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

The trainee may:

  • hold information about patients in confidence, unless the release of information is required by law or public interest
  • consider patients’ decision-making capacity
  • identify patients’ preferences regarding management and the role of families in decision making
  • not prioritise personal interest or professional agendas at the expense of patient or social welfare
  • share information between relevant service providers
  • acknowledge and respect the contribution of health professionals involved in patients’ care

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, risk, and uncertainty
  • use the best available evidence for the most effective therapies and interventions to ensure quality care
  • implement stepped care pathways in the management of chronic diseases and disabilities
  • recognise patients’ needs in terms of both internal resources and external support on long-term health care journeys
  • evaluate the benefits, costs, and potential risks of each investigation in a clinical situation
  • adjust the investigative path depending on test results received
  • consider whether patients’ conditions may get worse or better if no tests are selected

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

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
  • coordinate whole-person care through involvement in all stages of patients’ care journeys
  • use a multidisciplinary approach across services to manage patients with chronic diseases and disabilities
  • develop collaborative relationships with patients, families, carers, and a range of health professionals

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 optimal cost-effective patient care to allow maximum benefit from the available resources
  • use health screening for early intervention and chronic diseases management
  • assess alternative models of health care delivery to patients with chronic diseases and disabilities
  • participate in government initiatives for chronic diseases management to reduce hospital admissions and improve patients’ quality of life
  • help patients access initiatives and services for patients with chronic diseases and disabilities
  • select and justify investigations regarding the pathological basis of disease, appropriateness, utility, safety, and cost effectiveness
  • consider resource utilisation through peer review of testing behaviours

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
  • demonstrate awareness of government initiatives and services available for patients with chronic diseases and disabilities, and display knowledge of how to access them