Adult Endocrinology and Metabolism — Core of Discipline

C6 Documenting patient encounters

Key Features:
- This EPA focuses on writing a high-quality consultation note using any format: handwritten, dictated, electronic medical record.
- This includes a synthesis of the pertinent clinical findings, investigations, and management plan, as well as clear articulation of the role of the endocrinologist and the referring physician in further care. It may include linking the recommendations to evidence-based guidelines or other educational references for the referring physician.
- The documents submitted for review must be the sole work of the resident.
- This EPA may be observed in any care setting and with any patient presentation.

Assessment Plan:
Review of clinical documentation by supervisor
Use Form 1. Form collects information on:
- Type of documentation: new patient consultation note; returning patient note
Collect 4 observations of achievement
- At least 1 new patient consultation note
- At least 1 returning patient note
- At least 2 different observers

Form

F1: Observation

Milestones

• ME 2.2. Synthesize and interpret information from the clinical assessment

• COM 5.1. Organize information in appropriate sections

• COM 5.1. Document all relevant findings and investigations

• COM 5.1. Convey clinical reasoning and the rationale for decisions

• COM 5.1. Provide a clear plan for ongoing management

• COL 1.2. Identify clearly the roles of the referring physician and/or other relevant care providers and the endocrinologist in the ongoing management plan

• COL 3.2. Provide anticipatory guidance for results of outstanding investigations and/or next steps for management

• COM 5.1. Complete clinical documentation in a timely manner

Context Variables

• Type of documentation (single-choice)
  • new patient consultation note
  • returning patient note

Requirements

• Collect 4 observations of achievement (minimum 4)
• At least 1 new patient consultation note (minimum 1)
  • Only counts when Type of documentation is new patient consultation note
• At least 1 returning patient note (minimum 1)
  • Only counts when Type of documentation is returning patient note
• At least 2 different observers (minimum 2)
  • Counted once per distinct Assessor