Clinical Competency Rubric

2. Clinical information gathering and interpretation

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Table of contents

Last revised: 04 Mar 2024

This competency is about the gathering, interpretation and use of data or information for clinical judgement. This includes information gathered from the history, clinical records, physical examination and investigations. History-taking includes gathering information from other sources, such as family members and carers, where appropriate. Information gathering should be hypothesis-driven and used to confirm or exclude likely diagnoses and red flags. The physical examination, and the selection of appropriate and evidence-based investigations, are incorporated into this assessment area. This should be appropriate to the patient and presentation, and be evidence based.

Required knowledge

Critical evaluation of demographic data and health information
Human body and disease
Professional resources and guidelines

Required attitudes

Empathy
Ability to deal with uncertainty and ambiguity
Self-awareness
Curiosity

Professionalism

Commitment to learning and development
Respect for patient autonomy

Required skills

High-level communication skills (verbal and non-verbal including de-escalation skills)
Comprehensive history taking social, cultural and medical
Competent physical examinations

Skills focus: History, physical examination, investigations and how the clinical information is gathered

Criteria

History

A comprehensive biopsychosocial history is taken from the patient
All available sources of information are appropriately considered when taking a history

Physical examination

An appropriate and respectful physical examination is undertaken, targeted at the patient’s presentation and likely differential diagnoses
Physical examination findings are detected accurately and interpreted correctly
Specific positive and negative findings are elicited

Investigations

Rational options for investigations are chosen using an evidence-based approach
Interprets investigations in the context of the patient’s presentation

Performance lists

Criteria (competent at level of Fellowship)	Performs consistently at the standard expected
A comprehensive biopsychosocial history is taken from the patient	Obtains sufficient information to include or exclude any likely relevant significant conditions (red flags) Organises the history so that it is relevant and targeted to the presenting symptoms Follows up on patient cues to elicit positive and negative details Questions that are used are relevant and focused Integrates a mental state assessment into history taking as appropriate
All available sources of information are appropriately considered when taking a history	Refers to patient’s notes prior to the consultation, reviewing relevant information such as past medical history, specialists’ letters Considers information provided by third party such as family members or carer
An appropriate and respectful physical examination is undertaken, targeted at the patient’s presentation and likely differential diagnoses	Performs a systematic physical examination that is appropriately focused and not overly inclusive Obtains consent before performing an examination Enquires if the patient would prefer a chaperone present when undertaking an examination that could be intimate Positions the patient with consideration for their comfort, safety and modesty Explains the reasons for the examination and findings to the patient throughout Washes hands prior to performing a physical examination
Physical examination findings are detected accurately and interpreted correctly Specific positive and negative findings are elicited	Uses recognised physical examination techniques Uses the examination findings to confirm or exclude possible diagnoses Appropriately selects and uses tools to aid physical examination (eg ophthalmoscope)
Rational options for investigations are chosen using an evidence-based approach	Selects appropriate investigations for the patient presentation and likely diagnosis Selects relevant investigations in an appropriate sequence Considers which diagnostic tests are likely to be the most beneficial to the health of the patient Considers costs when requesting investigations Considers issues of access when requesting investigations
Interprets investigations in the context of the patient’s presentation	Accurately interprets investigations Interprets investigations taking into consideration the patient’s history, current presentation, and current medication
Aboriginal and Torres Strait Islander health context Identifies and addresses obstacles to optimising the management of complex health presentations in Aboriginal and Torres Strait Islander peoples
Rural health context Works effectively with patients who live in isolation

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