Clinical Competency Rubric 2022

2. Clinical information gathering and interpretation

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

  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

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

Investigations

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


Performance lists

Criteria (competent at level of Fellowship) Performs consistently at the standard expected
  1. 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
  1. 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
  1. 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
  1. Physical examination findings are detected accurately and interpreted correctly
  2. 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)
  1. 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
  1. 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
  1. Identify and address obstacles to optimising management of complex health presentations in Aboriginal and Torres Strait Islander peoples
 

Rural health context

  1. Work effectively with patients who live in isolation
 
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Related documents

  Clinical-Competency-Rubric (PDF 0.39 MB)

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