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)