- Appropriately uses the computer/IT systems to improve patient care in the consultation
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- Uses the computer effectively during the consultation without this interfering with patient communication
- Uses the IT systems available to access recall systems, relevant patient data
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- Maintains comprehensive and accurate clinical notes
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- Records are timely and accurate
- Patient notes are up to date, clear and accurate
- Clear and precise documentation of diagnosis in patient notes
- Clear and precise documentation of management and follow up plans
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- Written communication is clear, unambiguous and appropriate to the task
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- Referral letters are legible, and clearly state the purpose of the referral
- Instructions to the patient are legible, in language that the patient can understand
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- Demonstrates efficient use of recall systems to optimise health outcomes
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- Uses a recall system to ensure appropriate follow up of patient results
- Uses a follow up system to ensure appropriate follow up of agreed management steps
- Describes the systems used to identify and notify individuals in need of follow up
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- Accurately completes legal documentation appropriate to the situation
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- Describes the legal requirements when undertaking assessment and reporting of fitness to drive
- Describes the legal requirements when undertaking work capacity certificates
- Describes the considerations of work capacity certificates
- Describes the legal requirements and considerations of death certification
- Describes mandatory reporting requirements (eg reporting an impaired colleague to Ahpra)
- Describes incident reporting for quality improvement within the practice
- Manages capacity assessment and certification
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- Implements best-practice guidelines for infection control measures
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- Regular practice of appropriate hand hygiene
- Can discuss body fluid spills management Immunisation of self and staff
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- Patient confidentiality is managed appropriately
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- Keeps information identifiable to an individual private
- Manages exceptions to this obligation such as when there is a legal subpoena or requirements for mandatory reporting
- Describes situations when there is an exception to patient confidentiality requirements
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- Informed consent is explained and obtained
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- Provides accurate and comprehensive information tailored to the individual, the options available and the risks and benefits of these options
- Gains consent for physical examination, procedures, management plans and to have a third- party present in the room for educational purposes
- Describes how capacity to provide consent is determined
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Aboriginal and Torres Strait Islander health context
- Uses specific Medicare and Pharmaceutical Benefits Scheme programs to improve health outcomes
- Appraises the capacity of the primary healthcare model to comprehensively meet the needs of the community
- Develops strategies to promote a culturally safe practice environment
- Appropriately uses Medicare programs in the delivery of healthcare for Aboriginal and Torres Strait Islander patients
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Rural health context
- Sets up systems to optimise time management for the practice in a rural community with limited resources
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