2. Clinical information gathering and interpretation

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

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

Physical examination

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

Investigations

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

4. Identifies and addresses obstacles to optimising the management of complex health presentations in Aboriginal and Torres Strait Islander peoples

6. Works effectively with patients who live in isolation