Entrustable Professional Activities

LG 6: Assessment and treatment planning

Learning Goal 6

Assessment and treatment planning

Evaluate patients using a comprehensive addiction medicine assessment

This activity requires the ability to:

  • perform a comprehensive substance use and behavioural addiction history
  • elicit medical, psychiatric, and psychosocial history
  • assess level of intoxication or withdrawal
  • perform a physical examination
  • perform a mental state examination, including assessment of delirium
  • complete a risk assessment, including of harm to self or others
  • select and use laboratory tests and clinical investigations
  • establish the diagnoses, relevant antecedent factors, and sequelae
  • complete a set of agreed problems and goals with the patient
  • develop a management plan
  • respond to questions in medicolegal assessments

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
    • comprehensive substance use and behavioural addiction histories
    • medical histories with a focus on, but not limited to, substance use-related harms, such as blood borne virus infections, respiratory COPD, sleep apnoea, cardiovascular problems, and liver disease
    • psychiatric histories, assessing the interaction between patients’ substance use, any behavioural addictions, and mental health
    • psychosocial histories, considering the effect of early development and trauma and patients’ social environments in the aetiology and continuation of addictions
  • perform mental state examinations, including cognitive assessment
  • perform physical examinations assessing degree of intoxication or withdrawal, and physical harms associated with substance use, as well as co-existing medical disorders
  • perform risk assessments, considering risks to the patient and to others
  • perform relevant laboratory tests and other clinical investigations
  • clarify areas of uncertainty by seeking out alternate information sources, with attention to ethical issues
  • consult appropriately with other specialists, including with psychiatrists and emergency care staff
  • establish the diagnoses according to relevant guidelines, such as the current International Classification of Diseases (ICD) and/or Diagnostic and Statistical Manual of Mental Disorders (DSM), and relevant antecedent factors and sequelae
  • formulate the severity, associated risk, and clear chronology of patients’ substance use and behavioural addiction histories
  • complete sets of agreed problems and goals with patients
  • consider current legislation relating to patients’ presentations and possible treatment options
  • develop management plans based on patients’ readiness to change with the patient and other health professionals, using:
    • culturally safe interventions and services for Māori and Aboriginal and Torres Strait Islander peoples and populations
    • peer support groups
    • non-government and private services
    • private addiction specialists
  • encourage and facilitate recovery, including improvement in personal health and wellbeing, participation in work and social activities, interpersonal relations, and housing
  • respond to questions in medicolegal assessments, taking into consideration all sources of information
  • determine when it is appropriate to engage with family members to support the patient
  • apply harm reduction measures wherever possible
  • practice in a culturally safe manner and in recognition of the impact of any trauma patients have experienced
  • manage behavioural emergencies, such as withdrawal states, intoxication, and acute mental health presentations

direction
Requires some supervision

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

The trainee may:

  • elicit psychiatric and psychosocial histories, but not fully integrate them into an understanding of patients’ current predicaments
  • construct management plans that are inconsistent with patients’ priorities and readiness for change, and that do not address opportunistic harm reduction

Communication

confident
Ready to perform without supervision

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

The trainee will:

  • develop a therapeutic alliance with patients through respectful communication, active listening, and acknowledgement of patients’ views during consultations
  • use clear and adequate communication in handover with other health professionals and those involved in patients’ treatments
  • communicate with patients’ other treating health professionals to facilitate clear planning and/or handover
  • negotiate respectfully with other team members, acknowledging their expertise, when developing management plans for patients
  • document management plans, and share with other involved providers in a timely manner

direction
Requires some supervision

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

The trainee may:

  • compose detailed letters and/or summaries to health professionals, especially the referring doctor and usual GP
  • communicate management plans in their entirety

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:

  • create well structured, documented and individualised assessments and management plans
  • use standard assessment tools, as required, for particular clinical scenarios, such as withdrawal, cognitive impairment, and sedation levels
  • communicate management plans effectively within the clinical context, such as hospital settings requiring multimodal and multilevel communication
  • undertake audits of records on a regular basis, and revise assessment and care planning processes accordingly
  • use relevant national and state standards, such as Austroads’ Assessing Fitness to Drive and Waka Kotahi NZ Transport Agency’s Medical Aspects of Fitness to Drive, in assessments regarding motor vehicle licencing

direction
Requires some supervision

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

The trainee may:

  • create broad plans and non-individualised documentation

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:

  • organise regular junior staff observations, especially during the early phases of learning
  • verify that junior team members’ use of patient-centred interview styles, assessment structure, and management plans are clearly documented and evidence based
  • model good communication at all levels, both with patients and fellow health professionals

direction
Requires some supervision

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

The trainee may:

  • instruct more junior staff on assessment and 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:

  • demonstrate an understanding of the evidence behind various elements of assessment, including the strengths and weaknesses of various tools
  • use evidence-based interventions in development of treatment and management plans

direction
Requires some supervision

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

The trainee may:

  • use evidence selectively
  • adhere to certain assessment strategies or tools without consideration of their relative strengths and weaknesses
  • not be sufficiently flexible in accommodating patients’ preferences and wishes, and resource limitations

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:

  • describe the complex historical and contemporary factors that drive substance use and addictive disorders in some Māori and Aboriginal and Torres Strait Islander peoples and populations
  • assess patients in a culturally safe manner
  • recognise the importance of culture as important aspects of patients’ wellbeing, especially family, relationships, and mental and spiritual health
  • recognise the importance of involving family and carers in a culturally safe way
  • assess information gained during assessments and in formulation of management plans

direction
Requires some supervision

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

The trainee may:

  • demonstrate difficulty engaging patients in a culturally safe manner, not adjusting communication styles according to the cultural needs of patients, families, and/or carers

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:

  • evaluate risks and benefits of various interventions, acknowledging patients’ right to autonomy
  • incorporate principles of shared decision making with patients
  • evaluate risks and benefits of various interventions, acknowledging patients’ right to autonomy
  • plan management outside of guidelines after conferring with appropriate colleagues
  • use flexible approaches to assessment and care planning with the correct precautions in place, which may result in better outcomes
  • use appropriate and validated tools for assessment
  • critique and scrutinise use of assessment strategies, tools, and the effectiveness of interventions throughout practice

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 from experienced clinicians or pharmacists 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:

  • conduct regular multidisciplinary team review meetings to discuss patients and share knowledge
  • negotiate with other team members and health professionals to agree on the actions necessary to achieve patients’ goals, and the support required to do so

direction
Requires some supervision

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

The trainee may:

  • participate in multidisciplinary meetings

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:

  • establish clear processes to access care and for others to make referrals, and ensure that patients are prioritised transparently
  • communicate with referring health professionals and agencies in a timely manner

direction
Requires some supervision

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

The trainee may:

  • identify and access relevant resources to support patients’ care