Adult Rheumatology — Foundation of Discipline

F6a Completing written documentation for uncomplicated patient encounters - Part A: Clinical Documentation

Key Features:
- This EPA focuses on the application of written communication skills, especially in outpatient settings, in a variety of formats: new patient letters; follow up notes; referral letters. This includes clear documentation of the assessment and plan, and timely completion.
- This EPA also includes documentation of medication prescriptions that consider patient specific factors (e.g. dose adjustment, adherence to monitoring) and patient safety (e.g. mitigating risk of secondary complications).
- The observation of this EPA is divided into two parts: clinical documentation; prescriptions.
- The documents submitted for review must be the sole work of the resident.

Assessment Plan:
Review of clinical documentation by supervisor
Use Form 1. Form collects information on:
- Document: new patient letter; follow up letter
Collect 4 observations of achievement
- At least 2 new patient letters
- At least 2 follow up letters
- At least 2 different assessors

Form

F1: Observation

Milestones

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

• ME 2.2. Interpret clinical information, along with the results of investigations, for the purposes of diagnosis and management

• ME 2.4. Develop recommendations for management that address the consult question

• 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

• COM 5.1. Complete clinical 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

Context Variables

• Document (single-choice)
  • new patient letter
  • follow up letter

Requirements

• Collect 4 observations of achievement (minimum 4)
• At least 2 new patient letters (minimum 2)
  • Only counts when Document is new patient letter
• At least 2 follow up letters (minimum 2)
  • Only counts when Document is follow up letter
• At least 2 different assessors (minimum 2)
  • Counted once per distinct Assessor