Internal Medicine — Transition to Discipline

TTD1 Performing histories and physical exams, documenting and presenting findings, across clinical settings for initial and subsequent care

Key Features:

- This EPA focuses on clinical assessment, verifying the skills achieved in medical school. It includes performing the history and physical exams on new patients as well as follow-up assessments, in any care setting. It includes completing clinical documentation, which may be an admission history, as well as orders.

- It does not include diagnosing and managing patient presentations nor formulation of changes in treatment plans.

Assessment Plan:

Direct observation or case review by supervisor

Use Form 1. Form collects information on:
- Type of patient visit: new patient; focused follow-up

Collect 2 observations of achievement
- At least 1 new patient visit
- At least 1 focused follow-up visit

Milestones

• ME 2.2. Elicit an accurate, relevant history

• ME 2.2. Perform a physical exam that informs the diagnosis

• ME 2.2. Synthesize patient information from the clinical assessment for the purpose of written or oral summary to a supervisor

• ME 2.4. Identify and/or monitor key clinical features in the implementation of a management plan

• COM 1.1. Communicate using a patient-centred approach that encourages patient trust and autonomy and is characterized by empathy, respect, and compassion

• COM 2.1. Conduct a patient-centered interview

• COM 5.1. Maintain accurate and up-to-date problem lists and medication lists

• COM 5.1. Document the essential elements of a clinical encounter using a structured approach

• COM 5.1. Present findings to supervisor

• COM 5.1. Document relevant patient care orders