Clinical Competency Rubric 2022

7. General practice systems and regulatory requirements

This competency is about understanding general practice systems - including appropriate use of administration and IT systems, the importance of effective record keeping, clinical handover and recall systems. It also requires an understanding of how primary care is organised in Australia, and the statutory and regulatory requirements and guidelines that are in place. Written communication skills can be assessed in this domain when referral letters and clinical notes are reviewed. Patient consent and maintaining confidentiality are also incorporated into this domain.

Required knowledge

  • Australian healthcare system
  • Legislation relevant to general practice
  • Professional resources and guidelines

Required attitudes

  • Professionalism

Required skills

  • Setting and up working with practice systems

Skills focus: Medical records, certification and legal requirements, recall systems, computer use and infection control.

Criteria

  1. Appropriately uses the computer/IT systems to improve patient care in the consultation
  2. Maintains comprehensive and accurate clinical notes
  3. Written communication is clear, unambiguous and appropriate to the task
  4. Demonstrates efficient use of recall systems to optimise health outcomes
  5. Accurately completes legal documentation appropriate to the situation
  6. Implements best practice guidelines for infection control measures
  7. Patient confidentiality is managed appropriately
  8. Informed consent is explained and obtained


Performance lists

Criteria (competent at level of Fellowship) Performs consistently at the standard expected
  1. Appropriately uses the computer/IT systems to improve patient care in the consultation
  • 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
  1. Maintains comprehensive and accurate clinical notes
  • 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
  1. Written communication is clear, unambiguous and appropriate to the task
  • 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
  1. Demonstrates efficient use of recall systems to optimise health outcomes
  • 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
  1. Accurately completes legal documentation appropriate to the situation
  • 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
  1. Implements best practice guidelines for infection control measures
  • Regular practice of appropriate hand hygiene
  • Can discuss body fluid spills management Immunisation of self and staff
  1. Patient confidentiality is managed appropriately
  • 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
  1. Informed consent is explained and obtained
  • 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
Aboriginal and Torres Strait Islander health context
  1. Use specific Medicare and PBS programs to improve health outcomes
  2. Appraise the capacity of the primary health care model to comprehensively meet the needs of the community
  3. Develop strategies to promote a culturally safe practice environment
  4. Appropriately use Medicare programs in the delivery of healthcare for Aboriginal and Torres Strait Islander patients
 

Rural health context

  1. Set up systems to optimise time management for the practice in a rural community with limited resources
 
This event attracts CPD points and can be self recorded

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Related documents

  Clinical-Competency-Rubric (PDF 0.39 MB)

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