2. Clinical information gathering and interpretation

Download PDF

Table of contents

CS2.2 General practitioners diagnose and manage the full range of health conditions in a diverse range of patients, across the lifespan through a therapeutic relationship.
CS2.3 General practitioners are informed and innovative

This competency is about the gathering, interpretation and use of data 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 as well as 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 also be evidence-based.

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

Aboriginal and Torres Strait Islander health context

Identify and address obstacles to optimising management of complex health presentations in Aboriginal and Torres Strait Islander peoples

Rural health context

Work effectively with patients who live in isolation

For the trainee

The focus here is on the steps leading up to formulating a working diagnosis, relevant differential diagnoses and a problem list. Using a safe diagnostic strategy and describing how you developed a specific problem list are assessed in this area. By formulating a clinically appropriate working diagnosis, you demonstrate diagnostic accuracy. This does not require the correct diagnosis but that the direction of your reasoning was appropriate and accurate.

Did you know you can now log your CPD with a click of a button?

Create Quick log