Clinical Competency Rubric

7. General practice systems and regulatory requirements

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Table of contents

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

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

Performance lists

Criteria (competent at level of Fellowship)	Performs consistently at the standard expected
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
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
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
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
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
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
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
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 Use specific Medicare and PBS programs to improve health outcomes Appraise the capacity of the primary health care model to comprehensively meet the needs of the community Develop strategies to promote a culturally safe practice environment Appropriately use Medicare programs in the delivery of healthcare for Aboriginal and Torres Strait Islander patients
Rural health context Set up systems to optimise time management for the practice in a rural community with limited resources

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