Competency information
Details
Document all aspects of patient contact in accordance with record keeping procedures
Considerations
- Medicolegal requirements of health documentation
- Procedures of record keeping (legislative and local)
- Patient confidentiality, data protection, freedom of information
- Clinical audit procedures
Individual clinical responsibility and accountability
Relevant learning outcomes
| # | Outcome |
|---|---|
| # 3 | Outcome Interview a variety of different patients, overcoming any communication barriers |
| # 4 | Outcome Iinterpret test results and consolidate these in relation to all other relevant information obtained, and make informed decisions concerning the diagnosis and management options |
| # 7 | Outcome Write reports/letters regarding the outcome of the consultation and provide patients/carers with an agreed individual management plan (IMP) |