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Prepare for Practice Assessment
2021 Exit ExaminationHKCFP
2 April 2020
Nature of Practice Assessment
Workplace based (family medicine clinic)
Organizeand
manage
Application of skills
knowledge
Practice Assessment consists of two Sessions
Session I Today’s
theme
Session II
PMP report
Clinical supervisor
PA Examiners
• Practice setting (Part A)
• Clinic management (Part B)
• Pharmacy (Part C)
• Dangerous drug management (Part CII)
• Random check (PMP review)
• Dangerous drug management (Part CII)
• Medical records (Part D)
• Investigations (Part E)
Workshop in
the coming
August
Attachments
Session I
Use the latest version
• Worked in the practice for at
least three months
• Must be the same as the
Session II
HKCFP
Higher Training
Assessment Tool
You
Higher FM training
clinical supervisor
Any day between May 1, 2020
and Oct 31, 2020
Prepare Practice Management Package (PMP) Report
Marking principle, Appendix
NA
Marking Principle
• Knowledge of the candidate
• Actual Practice in the clinic
Appendix:
• Available at HKCFP website
• Information helps candidates to
prepare PMP report
Clinical
Supervisor
In addition, please pay attention to updates in:
• Evidence based practice
• Local legislation
Attachments
What are these?
Attachments 1 to 11 • Your clinic’s information, operation
protocols; etc• Have to be PRACTICAL• to be shown to your assessor in the
Session I
Attachments 12 and 13: • For Session II• To be compiled in a specified period
(~ mid September to end of October)
Prepare them now!
Attachments
Refer to Candidate’s Workshop in the coming August for details
Items marked with *
Mandatory for passing the respective Part (A / B / C) of the PMP
The whole Part (A / B / C) of the PMPwill be marked ‘fail’
Practice Management Package (PMP)Part A (Practice setting)
Sample Sample
Practice Management Package (PMP)Part A (Practice setting)
Sample Sample
Practice Management Package (PMP)Part A (Practice setting)
Sample Sample
Grading and comment by assessor
Clinical
Supervisor
Part B (Clinic Management): marking principle same as Part A
SampleSample
Sample
Part C (Pharmacy and Drug Labeling) marking principle same as Part A
SampleSample
Part C II (Dangerous Drugs Management): Checklist
SampleSample
Your knowledge/ practice on five areas:1. Authorized persons2. DD receptacle3. DD storage, check for expiry4. Expired DD5. DD register
Part C II (Dangerous Drugs Management)
Part C II (Dangerous Drugs Management)
Sample
Clinical supervisor’s verification
Pass grade in: • Part A, B, C, CII • Overall
Completing Practice Management Package (PMP) Report
PMP report
Submitting PMP report
• To be submitted with the Exit Examination Application
(the deadline usually on the 1st working day of November)
• Prerequisite to proceed Session II of PA Segment
• Random check (PMP review) in Session II will be based on
your PMP report
• Study
o Instrument, set-up, facilities, clinic operation / workflows listed in PMP
o Understand, familiar, and able to tell your medical colleagues on
❖ How they work
❖ Their service record keeping and documentations
• At PMP visit (Session I): if you discover something not right:
o Try to amend, improve it,
o liaise with your clinic team members / clinic in-charge / service head
• At the Exam (Session II): if you discover something not right:
o Keep calm
o Point that out in a non-confrontation manner
o Discuss on the way to amend/ improve it
Some tips
• Relying too much on the (copies of) materials used by previous
candidate(s) in your clinic
• At Session II (Random Check, Part C II):
o Hesitate a lot in answering questions
o Needed your clinic staff to give lots of supplementary
information to the PA Examiners
o Search around as if looking for a lost item in the clinic
o Flip back and forth the clinic menu as if never read it before
Some tips
Session IIWorkshop in
the coming
August What can I do
now?
More information:
Part D(Medical records)
24
Reference on medical record keeping Tips on Good
practice
25
Part D (Medical Records): general requirementsWhat
to prepare
300 Medical records
of the patient that consulted you
within a six-week period from mid-September to end of October
Summarize the medical records in
table form
26
Head counts
Acceptable format of medical records
Print-out from computer system
AND / OR
Handwritten records
Attachment 12
Preventive care
Consultation noteDr. Candidate
Consultation noteDr. Co-worker B
Consultation noteDr. Candidate
Consultation noteDr. Co-worker A
Each of them should, at least (e.g. print out from computer), include:
Lab report
Referral letter
Patient information
Chronologically the previous five consultations’ notes (as applicable):
For examiner’s reference
The date seen by you as stated in your Attachment 12
Some information in the past consultation notese.g. Blood pressure, BMI; chronic medications usage, controlof medical condition(s) under your clinic’s attentionmay affect the examiner’s judgement of your consultation note
D2
D3
D4
on those results you handled / followed up in D4(as applicable)
those you issued in D4 (as applicable)
What to
prepare
Part D: content of the medical records expected
27
What is D2, D3, D4 ?
Next Page
Part D: When Examiners in your clinic What will be
assessed
You can briefly show the basic layout of your medical records to the Examiners
Basic information is charted here …; the lab reports are …
They will read and assess the records independently in your absence
They will mark on four areas:D1 (Legibility)
D2 (Basic information)
D3 (Anticipatory / preventive care in the recent 12 months)
D4 (Consultation notes)
They will choose ten records from your Attachment 12 for assessment
28
D1 (Legibility)
Legible→ Examiners proceed to assess the record
Illegible→ the whole case will not be markedpro-rata mark deduction in Part D total score
Use abbreviations sensibly
• Understood by most general practitioners
• Can prepare a ‘reference list of abbreviations’ for the
Examiners: but all subject to the Examiner’s judgments29
Tips on Good
practice
What will be
assessed
D2 (Basic information)
About Current medication list: refers to the regular medications from your clinic
• preferred• Should have significant
‘negatives’ e.g. Allergy: nil known
• Inappropriate ‘blanks’ on the template/ table may be regard as missing information
• At least (but not limited to) 2 generations
• Relevant & specific for the patient
• Show index patient• Family members’ health
condition or if deceased: cause & age of death
• Show members who are living together
✓ dated✓ updated ✓ consistent with other parts
of the medical record
30
Areas to be examined Templates/ tables Genogram
Tips on Good
practice
What will be
assessed
•
•
•
•
31
D2 (Basic information): GenogramWhat will be
assessed
D3 (Anticipatory / preventive care in the recent 12 months)What will be
assessed
• preferred• Should have significant
‘negatives’ • Inappropriate ‘blanks’ on
the template/ table may be regard as missing information
✓ dated✓ updated ✓ consistent with other parts of the medical record
• Growth chart: for pediatric patients• Immunization: appropriate to patient’s age /
contemporary risk• Relevant action and review: e.g. on BMI/
overweight; high BP; smoking
32
Areas to be examined Templates/ tables
Attachment 12 (Part D)
Serial no.
Patient record number
Patient initials
sex age diagnosis Date of the consultation
Date of first attended the clinic
1 3216 NFK F 25 URTI 20 SEP 2011 18 OCT 2010
2 8839 LKF F 46 DEPRESSION 20 SEP 2011 25 JUL 2011
3* 292 KPW M 87 DM, HT, HYPERLIPIDEMIA
21SEP 2011 18 SEP 1999
33
D4 (Consultation notes) What will be
assessed
D4 (Consultation notes) What will be
assessed
34
Tips on Good
practice
Areas to be examined
D4 (Consultation notes): about good historyTips on Good
practice
“a good history” must mean an appropriate and
suitably discriminating history…
this means asking the right question, not every
question (Hoffbrand 1989)
From:Robin C. Fraser. Clinical Method: A general practice approach. 3rd edition
Tips on Good
practice
36
Some more tips on keeping good consultation notes
Diagnosis
1. Straightforward episodic cases →state the diagnosis would be
sufficient
2. Examples of differential diagnoses (ddxs) • Dizziness; ddx: BPPV,
vestibulitis
• Weight loss: bowel
pathology?, hyperthyroid
• LUTS: BPH, Co-existing UTI?
3. Status of control in chronic disease e.g. • HT, stable
• DM suboptimal control
• lipids on statin, at target
4. Psycho-social status as appropriate; e.g. • Dementia, care-taker stress
• Depression, recently
employed
Clinical Findings Follow up
1. Avoid loaded with less
relevant past information
2. Follow up significant issue(s)
raised in previous visits; e.g.
overweight, smoking,
elevated blood pressure
3. Idea/ concern/ expectation
(ICE) worth record if:
• Volunteered by the
patient/ relatives;
• In complicated situations
e.g.
suboptimal chronic
disease control,
diagnostic difficulty,
distressed patient
1. ‘Fixed’
for review of current
problems
2. ‘Open’ with advice e.g.
To return if no improvement
within one week (a set period
of time) or rash (dramatic
change in the condition e.g.
rash) develop
(History, Physical Examination)
Part E(Investigations)
37
Part E (Investigation): general requirements
On the exam date:
provide a room of adequate audio-visual privacy
for up to three examiners to assess your records
Same as Part D
What to
prepare
Summarize
the 10 cases
Medical records of
ten patients;
whom had investigations
initiated and followed
up by the candidate
in the same period as Part D
38
Attachment 13
What to
prepare
Investigations initiated, ordered, documented in the medical recordby the candidate
Can come from the 300 cases listed in your Attachment 12 (Part D)
The results are followed up, documented by the candidatewithin the six-week period as specified in Part D
If follow up consultation not possible, follow up by:
document in the medical record!
Part E: find 10 suitable cases for exam
within the six-week periodas specified in Part D
39
What to
prepare
The case can be:
• Patient’s complaint(s) in episodic/ regular visit
• Monitoring of existing / chronic medical condition
The case cannot be, just for the purpose of:
• Health screening / Medical assessment• Monitoring of possible side effects of
medication/ treatment in asymptomatic patients,
e.g. RFT after using ACEI; Blood liver enzymes after statins; CBP to screen neutropenia on carbimazole
For each case
• assign an ICPC-2 code to the Provisional diagnosis /
Chief condition that necessitate the investigation(s); e.g. T90, R74
• show the code on your summary (Attachment 13)
Among the ten cases • No more than two cases should belong to the
same ICPC - 2 “Chapter” (the alphabet)
40
Part E: find 10 suitable cases for exam
Cases summaries of the ten patients
Confidentiality: Do not include patient’s name, HKID
and
Summary table
Case no: 1Patient initials:
Clinic record number:
Sex: Age:
Provisional diagnosis / Chief condition requiring investigations:(date of the consultation: DD/MM/YYYY):
ICPC-2 code
Investigations performed:
Results:
Follow up: (date: DD/MM/YYYY)
Comments:
What to
prepare
Attachment 13: in a standard format
41
Case No: 6 Patient initials: LKH Clinic record number: GOSY 1810XY21 Sex: M Age: 83
Provisional diagnosis / Chief condition requiring investigations:(date of the consultation: DD/MM/YYYY):
Weight loss, ? Bowel pathologyC/O Weight loss 6 to 7 Ib in last 3/12B O change from daily to once every 3/7PE GC sat, mild pallor, abd soft non-tender/ no mass….PR: empty no mass felt
ICPC-2 code
Investigations performed: CBC, CEA, thyroid function (TSH), stool Occult blood X 3
Results:CBC: Hb 9.8 (low), WBC 4.8, Platelet count 345, CEA 2.0 (ref < 3.0), TSH normal, Stool OB +ve X 1
Follow up: (date: DD/MM/YYYY)Results informedDiscussed with patient and daughter…Mx: referral to Surgical SOPC (seek early appointment)
Comments:
T08 (weight loss)
The code that best describe the case
• Optional; marks will not be deducted for leaving this section blank • For discussion on investigation justification, limitations of the performance, area of improvement,
possible remedial actions• Avoid : clinic protocols, departmental guidelines, literature references, expert opinions; or
general summary from the medical record
• Less than 300 words #
• Concise summary from the medical record
• Less than 300 words #
# Section(s) grossly exceed the 300 words limit may be blocked and cannot be seen by Examiners
What to
prepare
• Concise summary from the medical record
• Less than 300 words #
42
Case Summary (Attachment 13): a sample
Part E: When Examiners in your clinic What will be
assessed
Candidate can briefly show the basic layout of your medical records to the Examiners
Basic information is charted here …; the lab reports are …
Examiners will read and assess the records independently in your absence
Base on the medical records, Examiners will mark on four areas:E1 (Investigation indication documentation)E2 (Justification)E3 (Results documentation)E4 (Follow up)
Examiners had read your Attachment 13 before coming to your clinic
Candidates should have the ten medical records ready for assessment
43
Tips on Good
practice
Investigation can be performed for a number of reasons, some
diagnostic, others therapeutic (House, 1983):
• To confirm or to make more precise a diagnosis suspected …
• To exclude an unlikely but important and treatable disease, …
• To monitor the effect or side effect of medicine, ….
• To screen asymptomatic patients, e.g. cervical cytology …
• To reassure an anxious patient that nothing is seriously
wrong, …
• To convince a sceptical patient that something is wrong and
that lifestyle amendments should be made, e.g. liver function
in a heavy drinker.From:Robin C. Fraser. Clinical Method: A general practice approach. 3rd edition
But please note:
These two groups
of cases should not
be submitted for
the Exam
44
Reasons of performing investigations (E2)
Tips on Good
practice
The decision to investigate a patient …is based on clinical
judgement,
which is influenced by many factors –
• the clinical findings on history and examination (including social
and psychological factors),
• the doctor’s temperament and attitudes,
• the doctor-patient relationship, and
• organizational factors such as the availability of diagnostic
services,
• the time of the day or night, etc.
such decisions are often finely balanced.
In public setting, consider self-
finance basis as appropriate
From:Robin C. Fraser. Clinical Method: A general practice approach. 3rd edition
45
Decision of performing investigations (E2)
Tips on Good
practice
…clinicians should ask themselves before
requesting an investigation…
• Why am I ordering this test?
• What am I going to look for in the
result?
• If I find it, will it affect my diagnosis?
• How will this affect my management
of the case?
• Will this ultimately benefit the
patient?
From:Robin C. Fraser. Clinical Method: A general practice approach. 3rd edition
In general, investigations should be performed
only when the following criteria are satisfied:
• The consequence of the result of the
investigation could not be obtained by a
cheaper, less intrusive method, e.g. taking a
more focused history or using time
• The risks of the investigations should relate
to the value of the information likely to be
gained
• The result will directly assist in the
diagnosis or have an effect on subsequent
management
46
Decision of performing investigations (E2)
E2 (Justification)
• Employ test(s) that are recognized and accepted in local primary care setting
• Test(s) are in line with the patient’s problem(s), be aware of
under-investigations: omit test(s) that obviously help to solve the problem
over-investigations: order irrelevant / redundant test(s)
• Perform the test(s) at an appropriate time / interval (i.e. for disease monitoring)
• Balanced between tailor to individual needs and consistency in approaching similar clinical
problems e.g. in diabetes / hypertension annual screening, hyperlipidemia follow up
E4 (Follow up)
• Identify abnormal results
• Convey to the patient on the significance and implication of the test results
• Take appropriate action(s) according to facts on hand (i.e. both the clinical findings & tests results)
47
Some more tips on rational use of investigations Tips on Good
practice
Prepare for Part D and Part E
• e.g. try to collect cases for one week in your clinic, following the exam requirement
• seek colleagues/ seniors to review your cohort
• Advantage:
1. Familiar with the examination format/ requirement that may differ from your usual
practice
o Use of summary templates (D2, D3)o Collect cases with the investigations meet the requirement (Part E)o Writing succinct case summaries (Attachment 13)o Presentation of record for examination
2. Identify areas need to improve, e.g.
o Consultation documentation (D4)o Discriminating use of investigations (E2)o Follow up of the patient with the given results (E4)
3. Allow estimate of your: time spent / workload / clinic’s affordability (e.g. turn-over
time of imaging / laboratory reports)
Conduct a pilot case collection
Thank you
Enquires: Specialty Board, HKCFP (Alky / John)