Adult Rheumatology — Core of Discipline

C8 Completing written documentation for complex patient care

Key Features:
- Building on the skills of Foundations, this EPA includes writing consult letters and new patient letters for complex patients and communicating complex treatment and follow up plans.
- This EPA focuses on the timely and clear documentation of an assessment and treatment plan, as well as documentation of complex prescriptions and orders.

Assessment Plan:
Review of new patient letters, follow up notes, and prescriptions by supervisor
Use Form 1. Form collects information on:
- Documentation type (select all that apply): new patient letter; follow up letter; inpatient notes; complex prescription
- Prescription type: not applicable; biologic/targeted synthetic DMARD; complex intravenous immunosuppressive medication
- Complex case: yes; no
Collect 6 observations of achievement
- At least 2 new patient letters for a complex case
- At least 2 follow up letters for a complex case
- At least 1 of each prescription type
- At least 2 assessors

Form

F1: Observation

Milestones

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

• ME 2.4. Develop recommendations for management that address the consult question and consider the patient’s status and other health problems

• COM 5.1. Organize information in appropriate sections

• COM 5.1. Document all relevant findings and investigations

• COM 5.1. Document clinical encounters to convey clinical reasoning and the rationale for decisions

• COM 5.1. Provide a clear plan for ongoing management of complex patient presentations

• COM 5.1. Use language and terminology that is clear, succinct, accurate and respectful

• COL 1.3. Provide written documentation in a timely manner

• COL 1.3. Share expertise when acting in the consultant role, using referral as an opportunity to improve quality of care

• P 3.1. Adhere to professional standards related to documentation of prescriptions

Context Variables

• Documentation type (multiple-choice)
  • new patient letter
  • follow up letter
  • inpatient notes
  • complex prescription
• Prescription type (single-choice)
  • not applicable
  • biologic/targeted synthetic DMARD
  • complex intravenous immunosuppressive medication
• Complex case (single-choice)
  • yes
  • no

Requirements

• Collect 6 observations of achievement (minimum 6)
• At least 2 new patient letters for a complex case (minimum 2)
  • Only counts when Documentation type is new patient letter
  • Only counts when Complex case is yes
• At least 2 follow up letters for a complex case (minimum 2)
  • Only counts when Documentation type is follow up letter
  • Only counts when Complex case is yes
• At least 1 of each prescription type (minimum 1)
  • Only counts when Prescription type is biologic/targeted synthetic DMARD
• At least 1 of each prescription type (minimum 1)
  • Only counts when Prescription type is complex intravenous immunosuppressive medication
• At least 2 assessors (minimum 2)
  • Counted once per distinct Assessor