Adult Rheumatology — Foundation of Discipline

F6b Completing written documentation for uncomplicated patient encounters - Part B: Prescriptions

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 prescription by supervisor
Use Form 1. Form collects information on:
- Type of medication: DMARD; non-DMARD
Collect 2 observations
- At least 1 of each type of medication

Form

F1: Observation

Milestones

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

• ME 1.3. Apply knowledge of clinical pharmacology as it relates to therapeutic agents in rheumatologic disease

• ME 2.4. Adapt dosing recommendations for patient’s condition and body size and/or drug elimination route, as relevant

• ME 5.2. Apply strategies for risk mitigation when prescribing medications with significant adverse effects (e.g. bisphosphonates with steroids)

• COM 5.1. Write prescriptions legibly and clearly, with attention to atypical dosing and frequency

• ME 4.1. Monitor for medication toxicity and/or response to treatment

• P 3.1. Demonstrate knowledge of professional standards related to documentation of prescriptions

• ME 5.2. Select duration of medication supply based on risk of toxicity and/or non-adherence

Context Variables

• Type of medication (single-choice)
  • DMARD
  • non-DMARD

Requirements

• Collect 2 observations of achievement (minimum 2)
• At least 1 of each type of medication (minimum 1)
  • Only counts when Type of medication is DMARD
• At least 1 of each type of medication (minimum 1)
  • Only counts when Type of medication is non-DMARD