Training activity information
Details
Complete all post-consultation documentation to include collecting and maintaining accurate genetic records and the preparation of clinic letters appropriate to the consultation
Type
Entrustable training activity (ETA)
Evidence requirements
Evidence the activity has been undertaken by the trainee repeatedly, consistently, and effectively over time, in a range of situations. This may include occasions where the trainee has not successfully achieved the outcome of the activity themselves. For example, because it was not appropriate to undertake the task in the circumstances or the trainees recognised their own limitations and sought help or advice to ensure the activity reached an appropriate conclusion.
Reflection at multiple timepoints on the trainee learning journey for this activity.
Considerations
- Clinical phenotype and family history
- Commonly encountered medical terminology including that relevant to dysmorphology and cancer genetic histopathology
- Local and national policies regarding data security
- Systematic approach to collecting and maintaining comprehensive and accurate records that detail the rationale underpinning any interventions
- Local guidelines for letter writing
- Plain English
- Adaption of language, style and format depending on individual needs
- Genetic databases
Reflective practice guidance
The guidance below is provided to support reflection at different time points, providing you with questions to aid you to reflect for this training activity. They are provided for guidance and should not be considered as a mandatory checklist. Trainees should not be expected to provide answers to each of the guidance questions listed.
Before action
What does success look like?
- Identify what is expected of you in relation to completing all post-consultation documentation, including the key governance, policies and guidelines related to collecting and maintaining accurate genetic records and preparing clinic letters appropriate to the consultation.
- Discuss what is expected of you in relation to the standards or templates used in your service, and expectations for documentation accuracy and completeness.
What is your prior experience of this activity?
- Think about what you already know about writing clinical notes, summaries, or letters.
- Consider possible challenges you might face during the activity, such as capturing all relevant information accurately and appropriately, writing clearly and concisely, maintaining confidentiality, or tailoring the letter to different recipients (e.g., patient, GP).
- Recognise the scope of your own practice for this activity i.e. know when you will need to seek advice or help, and from whom. You will need to seek advice when required, for example if the clinical letter requires complex phrasing or involves sensitive family information that needs specific communication management.
What do you anticipate you will learn from the experience?
- Consider the specific skills you want to develop, such as structuring and documenting consultations and written communication (drawing upon previous experiences of the activity).
- Identify the specific insights you hope to gain into the importance of accurate documentation for patient care, communication with colleagues, and legal requirements.
What additional considerations do you need to make?
- Consult actions identified following previous experiences of documentation or written work.
- Identify important information you need to consider before embarking on the activity, such as the timeframe for completing documentation, access to templates or examples, and what information from the consultation must be prioritised for inclusion.
In action
Is anything unexpected occurring?
- Are you noticing anything surprising or different from what you anticipate whilst completing the post-consultation documentation?
- Are you encountering situations such as:
- You struggled to recall a specific detail from the consultation or found the case unexpectedly complex to summarise?
How are you reacting to the unexpected development?
- How is this impacting your actions? For example, are you responding to the situation appropriately? Are you considering adapting or changing your approach to real-time gathering of information in consultations?
- Consider the steps you are taking in the moment, such as immediately consulting external notes or audio recordings to verify the specific detail or seeking clarification from a colleague regarding the required documentation format for a complex case.
What is the conclusion or outcome?
- Identify how you are working within your scope of practice. For example, were you able to complete the documentation accurately and appropriately, including all necessary patient identifiers and actions?
- What are you learning as a result of the unexpected development? For example, are you learning in that moment about balancing clear and concise information with the need for a detailed summary, including confidential information about other individuals in the family?
On action
What happened?
- Begin by summarising the key steps you took when collecting information, maintaining records, and preparing the clinic letter.
- Consider specific events, actions, or interactions which felt important, such as struggling to recall a specific detail from the consultation.
How has this experience contributed to your developing practice?
- Identify what learning you can take from this experience regarding documentation. What strengths did you demonstrate, e.g., meticulous accuracy in transcribing technical details?
- What skills and/or knowledge gaps were evident, e.g., unfamiliarity with specific requirements documentation?
- Compare this experience against previous engagement with similar activities – were any previously identified actions for development achieved?
- Has your practice improved in efficiency and accuracy in documentation?
- Identify any challenges you experienced, such as needing to seek advice or clarification on scope of practice regarding standardised documentation for complex psychosocial histories, and how you reacted to this.
What will you take from the experience moving forward?
- Identify the actions or ‘next steps’ you will now take to support the assimilation of what you have learnt, including from any feedback you have received, with regards to improving the speed and structure of post-consultation summarisation.
- What will you do differently next time you approach documentation, for instance, by proactively integrating a standardised template for capturing key information after the consultation?
- Do you need to practise any aspect of the activity further, such as writing formal clinic letters for varied recipients (patient, GP, specialist) or key learning outcomes related to maintaining patient records?
Beyond action
Have you revisited the experiences?
- How have your subsequent experiences of collecting/maintaining accurate genetic records and preparing clinic letters since completing this specific training activity led you to revisit your initial approach or decisions during that activity? For example, how a subsequent review of a clinic letter by a colleague prompted you to re-evaluate the conciseness and tailoring of your written summaries during your first attempt at this training activity.
- Considering what you understand about written communication, synthesis of complex information, and continuity of care now, were the actions or considerations you identified after your initial reflection on this training activity sufficient?
- How have you since implemented or adapted improvements in your documentation process based on further learning and experiences? For example, how you proactively implemented a structure for summarising complex psychosocial history concisely and appropriately for different recipients (patient vs clinician), demonstrating you have adapted improvements based on further learning.
- Has discussing ambiguous documentation or inconsistent record-keeping or the impact of documentation errors changed how you now view your initial experience in this training activity? For example, how a documentation error led to a delay in follow-up care refined your understanding of the critical nature of meticulous data transcription and timely record maintenance.
How have these experiences impacted upon current practice?
- How has the learning from this initial training activity, in combination with subsequent documentation experiences, contributed to your overall confidence and ability in accurate and appropriate documentation? How has reflecting back on this specific training activity, combined with everything you’ve learned since, shaped your current approach to collecting and maintaining accurate genetic records and the preparation of clinic letters? How does this evolved understanding help you identify when something is beyond your scope of practice or requires escalation?
- Looking holistically at your training journey, how has this initial documentation experience, revisited with your current perspective, contributed to your development in meeting the learning outcomes related to applying counselling skills and making referrals?
Relevant learning outcomes
| # | Outcome |
|---|---|
| # 1 |
Outcome
Plan, structure, deliver and appropriately document Genetic Counsellor consultations. |
| # 4 |
Outcome
Apply communication skills and knowledge to provide genetic information to individuals and their families across a range of clinical situations being sensitive to patient information needs and the psychosocial and cultural context of the situation. |