Document the progress of patients in multiple settings
This activity requires the ability to:
- produce written summaries of care, including discharge summaries, clinic letters, and transfer documentation
- provide information for colleagues, health professionals, and patients
- prepare written correspondence that functions as a historical record of patients’ presentation, management and progress, including key points of diagnosis and decision making, and as a clinical handover tool to inform follow-up and coordination of care plans
- produce clinical documentation that summarises current issues and enables subsequent health professionals to understand the issues and continue care
- perform this activity in multiple settings, including inpatient and ambulatory care settings and in emergency departments.
Behaviours
Each EPA has lists of behaviours. The behaviours help trainees understand how they can improve, and help supervisors to make decisions about whether trainees can be trusted to do the task with supervision at a distance
Ready to perform with supervision at a distance
Expected behaviours of a trainee who can routinely perform this activity with supervision at a distance.
The trainee:
- produces medical record entries that are accurate in regard to history, examination findings, investigation results, impression, and management plans
- uses a structured approach to sequentially review, assess, and plan care of patients. This may be in the form of a traditional ‘presenting problem history, other history elements, examination, investigation results, impression or synthesis, management plan’ format; or in a systems-based structure, appropriate for severely or critically unwell patients or for multiple, complex problems
- creates an accurate and appropriately prioritised problem list in the clinical notes or as part of an ambulatory care review
Not yet ready to perform with supervision at a distance
Examples of behaviours of a trainee not yet ready to perform this activity with supervision at a distance.
The trainee may:
- create unstructured medical record entries reflecting haphazard thought processes or lacking an overall impression of the current clinical situation
- omit clinically significant history, examination findings, investigation results, or management plans
Ready to perform with supervision at a distance
Expected behaviours of a trainee who can routinely perform this activity with supervision at a distance.
The trainee:
- appropriately prioritises the creation of medical record entries as an important clinical activity
- produces legible and accurate records that clearly identify all people involved in the clinical encounter, such as the names of consultants, junior staff, other staff, and family members involved in discussions
- shares relevant and understandable information and documentation with patients regarding their healthcare
Not yet ready to perform with supervision at a distance
Examples of behaviours of a trainee not yet ready to perform this activity with supervision at a distance.
The trainee may:
- assign a low priority to the creation of medical record entries when ordering daily tasks, such as deferring it to the end of the day or clinic
- use language that may be offensive or distressing to patients or other health professionals
- include personal information regarding patients that is not relevant to their care
Ready to perform with supervision at a distance
Expected behaviours of a trainee who can routinely perform this activity with supervision at a distance.
The trainee:
- includes patients’ identification label, entry date and time, signature, printed name, designation, and contact details on notes
- updates documentation in a time frame appropriate to the clinical situation of patients
- maintains records sufficiently to enable optimal patient care and adequate coding
Not yet ready to perform with supervision at a distance
Examples of behaviours of a trainee not yet ready to perform this activity with supervision at a distance.
The trainee may:
- write an illegible signature with no accompanying name or position identification
- make illegible notes
- use ambiguous or inappropriate acronyms
Ready to perform with supervision at a distance
Expected behaviours of a trainee who can routinely perform this activity with supervision at a distance.
The trainee:
- maintains confidentiality of documentation and stores clinical notes appropriately
- demonstrates an understanding of the fundamental role of record keeping in safe and effective healthcare, both acutely and longitudinally
- complies with the legal requirements of preparing and managing documentation
- provides honest and accurate medical certification where required
Ready to perform with supervision at a distance
Expected behaviours of a trainee who can routinely perform this activity with supervision at a distance.
The trainee:
- recognises their own limitations and seeks help when required in an appropriate way
Not yet ready to perform with supervision at a distance
Examples of behaviours of a trainee not yet ready to perform this activity with supervision at a distance.
The trainee may:
- inadequately consult with senior colleagues
Ready to perform with supervision at a distance
Expected behaviours of a trainee who can routinely perform this activity with supervision at a distance.
The trainee:
- ensures that all important discussions with colleagues, multidisciplinary team members, and patients are appropriately documented
- reviews discharge summaries, notes, and other communications written by junior team members
Not yet ready to perform with supervision at a distance
Examples of behaviours of a trainee not yet ready to perform this activity with supervision at a distance.
The trainee may:
- produce documentation that is unclear to the other members of the multidisciplinary team