CLINICAL PRACTICE LOGBOOK - Tartu Ülikooli ... addition to clinical everyday work the student must practice the practical skills required for a doctor and participate in seminars

CLINICAL PRACTICE

LOGBOOK

Academic year 2015/2016

2

CONTENTS

Introduction ····································································································· 3 1. Family medicine ························································································ 12 2. Emergency medicine ··················································································· 36

3. Internal medicine ······················································································· 53 4. Surgery ··································································································· 76 5. Optional cycle ··························································································· 98 Practical skills ······························································································· 101

3

INTRODUCTION

About practice

To study the phenomena of disease without books is to

sail an uncharted sea — while to study books without

patients is not to go to sea at all!

William Osler (1849–1919), who was the first to take

students from the books among the patients

With these words, practice starts for you. Following are the main features of the practice arrangement.

▪ The duration of the practice is 36 weeks during which you should work: (a) at a hospital; and (b) at a

family doctor’s practice.

▪ At the hospital, cycles of (a) emergency medicine; (b) internal medicine; and (c) surgery should be

performed, each of which with a duration of at least 8 weeks. Usually, the student performs these cycles

in the same hospital, because: (a) the working environment is already somewhat familiar in the

beginning of each next cycle; and (b) the hospital can count on the student to a greater extent in the

division of work and the student can be better included in the everyday work. In the family practice, an

8-week family medicine cycle must be performed.

▪ Based on the remaining 4 weeks, one of the abovementioned cycles can be prolonged or an optional

cycle performed in a place chosen by oneself – at a clinic, institute or healthcare organizing institution.

The precondition for performing the optional cycle is the agreement of the site to accept you.

▪ Two practice cycles can be performed in foreign countries. To perform a practice cycle in a foreign

country, you have to: (a) sign a trilateral practice agreement with each practice site (the three parties here

are the practice site, the university and you); and (b) compose a syllabus and a practice plan. More

detailed requirements are available at http://www.ut.ee/et/oppimine/praktikale-valismaale.

▪ If you want to perform more than two practice cycles in a foreign country, you need a separate permit.

For this, you need to present a written justified application to the general supervisor of clinical practice.

▪ Practice distribution arrangements determine at which hospital or family medicine practice you will be

during these 36 weeks. Rotation schedule determines, how you will move between different departments

at a hospital.

▪ Distribution arrangements are agreed each year with the course starting practice, and these are

coordinated by the Student Assembly of the Medical Faculty (SAMF) and the general practice

supervisor. Rotation schedule is composed in the specific hospital, taking into account your wishes and

needs.

▪ The basis of distribution arrangements are 4-week periods – it means that a student is in one place for at

least 4 consecutive weeks. This year, the periods are:

http://www.ut.ee/et/oppimine/praktikale-valismaale

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I II III IV V VI VII VIII IX X XI XII

8.06 6.07 3.08 31.08 28.09 26.10 23.11 4.01 1.02 29.02 28.03 25.04

↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓

5.07 2.08 30.08 27.09 25.10 22.11 20.12 31.01 28.02 27.03 24.04 22.05

▪ Periods II and IV are presented in bold, as it would be reasonable to start the first hospital medicine cycle

on one of these two periods. The hospitals organize familiarizing events on the first days of periods II

and IV to help the student to get accustomed to everyday work. Winter holidays are between periods VII

and VIII. There are 2 weeks between period XII and the final exam.

▪ The rotation schedule is composed in the specific hospital taking into account the student’s wishes and

needs. If you want to perform the practice in a certain department or with a certain supervisor, you

should say it during the compilation of the rotation schedule.

▪ Can the cycle be performed at one or another department? The general answer is: If it is possible to fulfil

the requirements of the cycle in this department, it is allowed to be done in principle.

▪ The internal medicine cycle may be performed: at the department of (a) endocrinology; (b)

gastroenterology; (c) haematology; (d) cardiology; (e) children’s diseases; (f) infectious diseases; (g)

nephrology; (h) neurology; (i) pulmonology; (j) rheumatology; and (k) general internal diseases. The

surgery cycle may be performed: in the department of (a) abdominal surgery; (b) pediatric surgery; (c)

orthopaedics; (d) traumatology; (e) urology; (f) vascular surgery; and (g) general surgery.

▪ In addition to clinical everyday work the student must practice the practical skills required for a doctor and

participate in seminars during the practice. These activities are reflected in separate chapters at the end of

the practice logbook.

▪ The volume of the practice as a mandatory subject is 55 ECTS credits and it is assessed non-differentially.

At the end of period VIII filled chapters of at least 2 cycles should be presented to the general practice

supervisor. At the end of period XII the chapters of all cycles, the chapter of practical skills and

participation sheet of seminars should have been be presented. When the logbook has been presented and

the prelim passed, you can keep the logbook.

▪ Exceptions in the practice arrangement will be decided individually by the general practice supervisor.

About practice logbook

The practice has two goals: (a) to integrate the theoretical knowledge accumulated during the main studies;

and (b) to acquire practical skills required in everyday work. The purpose of the practice logbook is to help

you to achieve these goals. We have tried to include as few as possible fields that are used to check the

performance of practice. You should also fill the practice logbook so that it would be a job for you and no-one

else!

5

Family medicine, emergency medicine, internal medicine and surgery practice cycles have separate chapters

in the practice logbook. The structure of these chapters is relatively similar, containing three subdivisions: (a)

work with patients; (b) self-analysis; and (c) the supervisor’s assessment. If you decide to perform an

optional cycle during the practice, you should write (a) a self-analysis and get (b) supervisor’s assessment.

These subdivisions and their purpose are briefly described on the next page.

What has to be done? Why are we asking this?

▪ In the subdivision Work with the patients, you

will have to write a certain number of case

analyses (in family medicine practice cycle) or

hospital discharge summaries (in emergency

medicine, internal medicine and surgery practice

cycles). These should be presented to the

supervisor who reads them and confirms it with a

signature.

▪ The subdivision starts with the list of case

analyses or hospital discharge summaries and

continues with their basics. You will have only to

fill in the given basics.

▪ Additionally, you will have to note in this sub-

division the interesting or informative cases

you have seen in everyday clinical work. Do not

take it as a bothersome obligation – think how

interesting it would be to read them after many

years!

▪ The first aim of this sub-division is to direct with

the help of the list of topics which patients or

situations you should focus on during the

practice.

▪ The second aim is to practice the writing of

hospital discharge summaries. We hope that when

you have written a score of hospital discharge

summaries during emergency medicine, internal

medicine and surgery practice cycles, you will

remember their structure also in the future.

▪ Ultimately, we wish to motivate you to take your

time and think about the patient as a whole.

Remember, what you did and why? What is the

patient’s background – why did he or she come to

you? What happens with him/her in the future?

What can be learned from one or another case?

We presume that you will, nonetheless, have to

fill the hospital’s or family practice’s

documentation and there is no need to duplicate

it.

▪ Try to distribute your activities evenly with your

supervisor. If you will leave all case analyses or

hospital discharge summaries to the end of the

cycle you may not have time to focus properly. In

addition, your supervisor may not have an

opportunity to read them and offer informative

feedback. For example, agree to present one a

week.

6

What has to be done? Why are we asking this?

▪ In the self-analysis sub-division, you have to

present your thoughts about the performed cycle

on up to one page. For example, you can: (a)

write about what you saw and did during the

practice; (b) analyze your strengths and

weaknesses observed during everyday clinical

work; or (c) think what you would like and are

able to improve in yourself, family medicine

practice, hospital or the whole Estonian

healthcare system.

▪ Here, we also wish that you would take time to

think about what you experienced. We hope that

also the supervisor finds time to read this page –

and it would be especially great if a longer

discussion would begin from it.

▪ To get the supervisor’s assessment you will give

your logbook to the doctor who supervised you

most during the given cycle. He/she makes sure

that everything is done as it should be and then

evaluates you in four categories: (a) contact with

the patient and collecting history; (b) objective

examination of the patient; (c) theoretical

knowledge; and (d) participation in the everyday

work of the department or family practice.

▪ The supervisor does not assess you in free form,

but chooses between predetermined descriptions.

▪ The aim of this sub-division is to give you a

complete and honest feedback about your work.

▪ Do not despair if the supervisor has not put you

into the highest category in all categories. Even

an experienced doctor may not be objectively

excellent to the utmost. Better ask your

supervisor to decide, where and how you could

improve yourself. You both can only win from

the conversation.

The practical skills are common to all cycles and are presented in a separate chapter. We have listed 72

practical skills by topics that you could develop during the practice. Of these, 36 are mandatory – it means

that during the year, you have to show them to the supervisor – a doctor or a nurse – and get a signature for it.

Do not be afraid to tell your supervisor, if you have not performed some of these activities before! We

encourage you to think what an activity consists of with the help of literature and videos, if required, before

we ask, so the learning would be faster. Try to distribute your activities evenly – if you leave the presentation

of all your practical skills to the end of the last cycle, it will need a lot of time from you and your supervisor.

It is your choice, during which cycle you will present your skills, but try to use common sense: for example,

counseling activity is best practiced during the family medicine cycle, at the same time clinical death could be

most probably encountered during emergency medicine or internal medicine cycles.

In case of some activities, it may be not possible to show them to the supervisor during the practice – here, we

think about skills associated, for example, with a patient in critical condition. If it is so, do not worry –

describe your activities to the supervisor orally. In addition, the supervisor may mark the activity as performed

if he/she has seen you performing it repeatedly during the practice.

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Literature

All that we have learned during five years cannot be remembered at once during everyday clinical work –

therefore, there are shelves in the doctors’ rooms and books on the shelves. Whether you should obtain some

handbook for the practice, depends on your expectations and needs.

Most students have come into contact with the Oxford Medical Handbooks series during their studies. Most

clinical specialties are covered by Oxford Handbook of Clinical Medicine and Oxford Handbook of Clinical

Specialties. Oxford Handbook of Clinical Examination and Practical Skills gives a thorough overview of the

patient’s objective examination and practical skills. As the patients do not always visit a doctor with a

complete diagnosis, you may like the Oxford Handbook of Clinical Diagnosis, which presents most of

common complaints or objective findings with references to their basic pathology and further investigation

methods. Thoroughness and philosophical excursions are the strongpoints of this series, but this also means

that these books are sometimes too big for the pocket. Or if not, a book should be put into each pocket for

balance.

If you want something that would contain a minimum of philosophy and would be practical to the bone –

philosophy has its place, but it is not necessarily during on-call hours – the Pocket Notebook series that has

been composed for the students and residents of the Harvard University may be more suitable for you. Pocket

Medicine covers most of the clinical medicine, is oriented to everyday work and really fits in the pocket.

From the same series, Pocket Primary Care, Pocket Emergency Medicine and Pocket Surgery have also been

well received, but if you want to survive the whole clinical practice with the help of one book, this is probably

Pocket Medicine.

As all students come into contact with the antibiotic treatment in all cycles, it is recommended to keep at hand

the latest antibiotic treatment guidelines of the Tartu University Hospital (look for it at intranet.kliinikum.ee)

and the outpatient treatment guidelines of infections of the Estonian Society for Infectious Diseases (look for

it on the website www.esid.ee). In addition, you can find help and support from the Manual of the doctor-on-

call of the Children’s Clinic of the Tartu University Hospital, which is found in most hospitals. If your hospital

has composed its own guidelines, you should prefer them.

8

For the supervisor

At first, we wish to thank you. All basic studies of medicines are to some extent preparation for practice – this

makes you one of the most important persons of the main studies! Thank you for performing this task!

Clinical skills are acquired step-by-step. In medical training literature, Miller’s pyramid is discussed that

divides the acquisition of clinical skills into four stages – we loom at them with the help of an example of

performing and evaluating an ECG:

▪ Abstract knowledge. The young colleague knows that there is a (somewhat mystical) thing called ECG and

that functional status of the heart can be evaluated with this. He/she knows how the waves, intervals and

segments are transferred to the paper and how these are connected to the distribution of excitement in the

myocardium.

▪ Specific knowledge. ECG is no more mystical for the young colleague. He/she knows that limb electrodes

are put onto limbs and precordial electrodes into 2nd

to 4th intercostal spaces from around the sternum to

middle axillary line. He/she knows that the elevation of ST segment in several successive leads means a

call to the department of emergency cardiology and a lot more.

▪ Ability to show. If the young colleague is told that he/she must do an ECG and describe the findings, he/she

is able to: (a) handle a simple ECG machine; (b) put the electrodes into right places; (c) evaluate

systematically what is seen on the paper; and (d) make a correct clinical conclusion.

▪ Ability to do. The young colleague has acquired a certain skill regarding the above described and his/her

hand does not shake not as much as in the beginning.

None of these stages can be omitted and movement from one stage to the other requires consistent practicing.

When the student with bright eyes reaches you, his/her all clinical skills are on the level of specific

knowledge. The aim of the practice is to take him/her to the level of showing.

We have tried to include as few as possible fields that are used to check the performance of practice. When

reading the student’s logbook and giving him/her feedback, try to proceed from the idea that he/she has

performed the work for him/herself and no-one other!

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Contacts

General supervisor and specialty supervisors are responsible for smooth execution of the clinical practice from

the side of the Faculty of Medicine. General supervisor of the clinical practice helps to solve general problems

(for example, performing the practice in a foreign country and performing an optional cycle) and he/she must

receive the filled practice logbook for prelim. Specialty supervisors help to solve problems associated with

individual practice cycles.

Sulev Haldre

General supervisor of clinical practice

[email protected]

731 8507

Heli Tähepõld

Family medicine specialty supervisor

[email protected]

731 9215

Aleksander Sipria

Emergency medicine specialty supervisor

[email protected]

731 8414

Mai Rosenberg

Internal medicine specialty supervisor

[email protected]

731 8276

Margot Peetsalu

Surgery specialty supervisor

[email protected]

731 8232

Kätlin Puksand

SAMF practice workgroup

[email protected]

Practice coordinators in hospitals help to solve problems associated with specific hospitals - for example

composition of rotation schedule, access to hospital information systems, lodging.

Hiiumaa Hospital

Rahu tn 2, Kärdla

Gennadi Aavik

[email protected]

462 2783

East Tallinn Central Hospital

Ravi tn 18, Tallinn

Anne Sirge

[email protected]

606 7806, 5635 3445

Ida-Viru Central Hospital

Ilmajaama tn 12/14, Kohtla-Järve

Aime Keis

[email protected]

339 5064, 5699 1110

Järvamaa Hospital

Tiigi tn 8, Paide

Andres Müürsepp

[email protected]

384 8100

mailto:[email protected]










10

Kuressaare Hospital

Aia tn 25, Kuressaare

Viktor Sarapuu

[email protected]

452 0002

Southern-Estonian Hospital

Meegomäe küla, Võru vald

Agnes Aart

[email protected]

786 8502, 517 5662

Western Tallinn Central Hospital

Paldiski mnt 68, Tallinn

Merike Paat

[email protected]

666 5320, 515 9496

Läänemaa Hospital

Vaba 6, Haapsalu

Tõnis Siir

[email protected]

Narva Hospital

Haigla tn 7, Narva

Pille Letjuka

[email protected]

357 1820, 5645 7709

North Estonia Medical Centre

Sütiste tee 19, Tallinn

Andrus Remmelgas

[email protected]

617 1525

Põlva Hospital

Uus tn 2, Põlva

Koit Jostov

[email protected]

Pärnu Hospital

Ristiku 1, Pärnu

Veiko Vahula

[email protected]

447 3103

Rakvere Hospital

Lõuna põik 1, Rakvere

Sirje Kiisküla

[email protected]

322 9021, 517 4169

Rapla County Hospital

Alu tee 1, Rapla

Aivar Tooming

[email protected]

5599 5797

Tallinn Children’s Hospital

Tervise 28, Tallinn

Mari Laan

[email protected]

Tartu University Hospital

L. Puusepa 8, Tartu

Clinical practice specialty supervisors are the

practice coordinators in the Tartu University

Hospital












11

Valga Hospital

Peetri 2, Valga

Kristel Kivisild

[email protected]

766 5202

Viljandi Hospital

Pärna tee 3, Jämejala küla, Viljandi vald

Enno Kase

[email protected]

435 2022



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FAMILY MEDICINE

Family medicine practice cycle

Student’s data. These fields are completed by the student

First and last name Registry number

E-mail address Phone number

Performing practice cycle. The doctor supervising the student completes these fields at the end of the

cycle. We ask that you confirm the completion of different parts of the practice logbook with a mark in the

yes box and signature next to it.

The student has presented 8 case analyses, including:

▪ 5 case analyses on mandatory topics

▪ 3 case analyses on optional topics yes

The student has presented self-analysis yes

I have assessed the student’s consulting skills:

▪ in the middle of the family medicine practice cycle

▪ at the end of the family medicine practice cycle yes

I have assessed the student at the end of the practice cycle in the following

categories:

▪ contact with the patient and collecting the history

▪ objective examination of the patient

▪ theoretical knowledge and clinical thinking

▪ participation in the everyday work of the family doctor’s practice yes

Supervisor’s data. The doctor supervising the student completes these fields at the end of the cycle.

First and last name Doctor’s code

Family doctor’s practice Stamp

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1.1. Work with patients

During the family medicine practice cycle, you have to write 8 case analyses on pre-determined bases,

including: (a) 5 case analyses on mandatory topics and (b) 3 case analyses on the optional topics. In the next

table, you can keep account of already written analyses by making marks in box C (case analysis). After the

supervisor has read your case analysis, and is satisfied therewith, ask him/her to write his/her signature next to

the box.

Try to distribute your activities evenly with your supervisor. If you will leave all case analyses to the end of

the cycle, you may not have time to focus properly and your supervisor may not have the possibility to read

them and give comprehensive feedback. For example, agree to present one case analysis a week.

Topics of case analyses in family medicine

Mandatory case analyses

Unclear diagnosis C

Prevention C

Approach to chronic disease C

Monitoring child’s development C

Approach to acute disease C

Optional case analyses

Approach to patient requesting referral to specialist C

Home visit C

Approach to chronic disease C

Phone consultation C



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Approach to a patient with unclear diagnosis

Reason for coming to the visit

Disease history

Objective findings. Also, add the results of relevant analyses and investigations.

Differential diagnosis

Taking into account the reason for coming to the visit, what could be the danger signs and what could these

indicate?

Primary diagnosis

Initial approach. Substantiate briefly!

Further approach. If and when do you plan the next contact?

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Prevention


More important chronic diseases and their duration

Hazardous habits, social, work-related and inherited risk factors. Association with the reason for coming to

the visit.

Objective findings, results of relevant analyses and investigations. Do the chronic diseases have

complications?

What prevention activities did you plan together with the patient? What priorities were set? Where would

the patient need additional motivating and how can you help him/her?

Approach to the reason for coming to the visit as well as concurrent diseases. Pharmacological and non-

pharmacological treatment

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Approach to patient requesting referral to specialist

The requirements of the referral are presented in the Minister of Social Affairs regulation The conditions

and procedure for maintaining records of the provision of health services and preservation of the

documents thereof. Look at this regulation in the electronic Riigi Teataja at www.riigiteataja.ee. The

Estonian Health Insurance Fund has compiled a summary of requirements of e-consultation referral; you

will find this at www.haigekassa.ee/sites/default/files/perearstid/e-kons_kodukale_2015.pdf (not valid

abroad!).

e-consultation or

usual consultation

CITO


Objective findings, results of relevant analyses and investigations.

Clear and specific question to the specialist

What possibilities of the family doctor’s practice have been used to solve the patient’s problem? Are there

other unused possibilities? What would be needed to use them?

A referral must include: (a) symptom, syndrome or diagnosis hypothesis; (b) history; (c) important results of

objective examination; (d) performed analyses and investigations; (e) medications used by the patient; and

(f) specific question to the specialist. Were they there? If not, why?

If the patient was referred to specialist’s consultation as CITO, then why?

If the patient was referred to e-consultation, see if the reason for referral was consistent with conditions

agreed with specialty! The conditions you will find in the abovementioned Health Insurance Fund summary.

http://www.riigiteataja.ee/

http://www.haigekassa.ee/sites/default/files/perearstid/e-kons_kodukale_2015.pdf

17

Home visit

Reason for home visit

Did the home visit take place on the same day during the

same week

at an arranged

time

Was the home visit indicated? Substantiate shortly!

Disease history



Primary diagnosis



18

Approach to chronic disease


More important chronic diseases and their duration. If possible, note the risk level of complications or

mortality.


complications?

Review the treatment guidelines for the patient’s diseases. Does the patient’s recent monitoring and

treatment comply with the valid guidelines? If not, why?

What aspects of living with the chronic disease does the patient manage well? Where would the patient need

additional motivation and how can you help him/her?

Present the patient’s brief treatment and monitoring plan for the next year.

19

Approach to chronic disease


More important chronic diseases and their duration. If possible, note the risk level of complications or

mortality.


complications?

Review the treatment guidelines for the patient’s diseases. Does the patient’s recent monitoring and

treatment comply with the valid guidelines? If not, why?

What aspects of living with the chronic disease does the patient manage well? Where would the patient need

additional motivation and how can you help him/her?

Present the patient’s brief treatment and monitoring plan for the next year.

20

Monitoring a child’s development

Monitoring of the development of an infant and child is regulated by Health check guidelines for children

under 18 years old, which is available at www.ravijuhend.ee. Familiarise yourself with the guidelines and

examine how the regular health check and vaccination are distributed between the doctor and the nurses in

your family doctor’s practice!


What activity or activities named in the guidelines did you perform?

Did the child’s psychomotor development correspond to the age? How did you assess it? What is the further

approach?

Did the child’s speech development correspond to the age? How did you assess it? What is the further

approach?

National immunization schedule is one of the most important knowledge you take with you into the life.

Write it down here! Have all vaccinations been performed according to the child’s age? If not, why?

12 hours 1 year

1–5 days 2 years

1 month 6–7 years

2 months 12 years

3 months 13 years

4.5 months 15–16 years

6 months After every 10

years

Was the child vaccinated? Against which diseases? If the child was not vaccinated, then why?

http://www.ravijuhend.ee/

21

Phone consultation


Disease history


Primary diagnosis


What advice did you give to the patient by phone?

If you decided to invite the patient to the family doctor’s practice, then when? Substantiate your decision!

If you decided that this problem cannot be solved by phone, what did you recommend to the patient?

Substantiate!

What was the further course of the disease? Was the chosen tactics right? Would you have wanted to do

anything differently?

22

Approach to acute disease


Disease history

Objective findings. Add the results of relevant analyses and investigations.


Taking into account the reason for coming to the visit, what could be the signs of danger and what could

these indicate?

Primary diagnosis



23



Disease history




these indicate?

Primary diagnosis



24



Disease history




these indicate?

Primary diagnosis



25

Note on these pages the patients who taught something valuable to you. For example, you could write here if

during an approach to some patients: (a) you learned to use some unfamiliar medicine or treatment method; or

(b) you learned something valuable about communication with patients or colleagues.

Reason for coming to the visit, short history Interesting or informative aspect

26


27


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1.2. Self-analysis

Here you can: (a) write about what you saw and did during the practice; (b) analyse your strengths and

weaknesses observed during everyday clinical work; or (c) think what you would like to and are able to

improve in yourself, family medicine practice or the Estonian healthcare system in general.

Self-analysis

29

1.3. Supervisor’s assessment

The supervisor’s assessment in the family medicine cycle consists of two parts. In the first part, we ask you to give

evaluate the student’s consultation skills in the middle of the practice cycle as well as at the end of the practice cycle. We

use for this an adapted MAAS-Global scale consisting of two parts: (a) the student’s consultation skills by specific stages

of one consultation; and (b) the student’s general consultation skills.

In the second part, we ask you to evaluate the student in four categories: (a) contact with the patient and collecting

history; (b) objective examination of the patient; (c) theoretical knowledge; and (d) participation in the everyday work of

the family doctor’s practice. You do not have to evaluate in free form, but you can choose between predetermined

descriptions.

Remember, that not all students are and cannot be excellent to the utmost! We recommend: (a) to start with the rating C

(good); (b) think if the student corresponds to the description, is better or worse; and (c) then move correspondingly up or

down when answering.

The student’s consultation skills in the middle of the practice cycle

Skills by stages of one specific consultation. We ask to evaluate the student’s consultation skills on a scale from A

(excellent) to F (insufficient). For some questions you can also choose N (not evaluable).

Introduction

▪ The student gives the patient a chance to talk

▪ The student asks the patient the main reason for coming to the visit

▪ The student inquires if the patient has also other reasons for coming to the

visit

A

B

C

D

E

F

Repeated visit

▪ The student makes a summary of previous complaints and treatment

plan

▪ The student asks the patient about coping with current treatment

▪ The student asks the patient about changing complaints

N

A

B

C

D

E

F

Summary of reasons for coming to the visit

▪ The student makes a summary of reasons for coming to the visit and the

patient’s expectations

▪ The student names the reason why the patient came to the visit at that time

A

B

C

D

E

F

Objective examination

▪ The student instructs the patient clearly and explicitly

▪ The student explains during objective examination what he/she is

doing at that moment

▪ The student behaves considerately and respectfully with the patient

N

A

B

C

D

E

F

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Diagnosis or diagnosis hypothesis

▪ The student makes a summary of the findings of the objective

examination

▪ The student names the diagnosis or diagnosis hypothesis

▪ The student explains the relationship between objective findings and

the diagnosis

▪ The student describes the probable course and prognosis of the

disease

▪ The student asks the patient’s opinion

N

A

B

C

D

E

F

Further approach

▪ The student discusses the risks and benefits of different treatment

approaches

▪ The student asks the patient about treatment feasibility and compliance

▪ The student explains to the patient who does what and when


A

B

C

D

E

F

General consultation skills. Now, we ask you to evaluate the student’s consultation skills by most important categories

on a scale from A (excellent) to F (insufficient).

Examination

▪ The student inquires about the patient’s reasons for coming to the visit and

his/her expectations

▪ The student takes into account the patient’s family and work-related

background

▪ The student pays attention to the patient’s body language

A

B

C

D

E

F

Emotions

▪ The student inquires about the patient’s emotions

▪ The student reflects the patient’s emotions to an appropriate degree

A

B

C

D

E

F

Information communication

▪ The student divides the information logically and into units with

perceptible size

▪ The student’s use of language is easily understandable

▪ The student checks if the patient understands the information

A

B

C

D

E

F

Making a summary

▪ The summaries done by the student contain all relevant information


A

B

C

D

E

F

Structuring the consultation

▪ The student divides the consultation into clearly defined stages

▪ Consultation stages are logically ranked and temporally balanced

A

B

C

D

E

F

Empathy

▪ The student expresses interest about the patient verbally

▪ The student expresses interest with tone, gestures and eye contact

A

B

C

D

E

F

31

The student’s consultation skills at the end of the practice cycle

Skills by stages of one specific consultation. We ask to evaluate the student’s consultation skills on a scale from

A (excellent) to F (insufficient). For some questions, you can also choose N (not evaluable).

Introduction


▪ The student asks the patient about main reason for coming to the visit

▪ The student inquires if the patient has also other reasons for coming to

the visit

A

B

C

D

E

F

Repeated visit

▪ The student makes a summary of previous complaints and

treatment plan



N

A

B

C

D

E

F


▪ The student makes a summary of reasons for coming to the visit and

the patient’s expectations

▪ The student names the reason why the patient came to the visit at that

time

A

B

C

D

E

F





▪ The student behaves considerately and respectfully with the

patient

N

A

B

C

D

E

F



examination


▪ The student explains the relationship between objective findings

and the diagnosis


disease


N

A

B

C

D

E

F

Further approach


approaches




A

B

C

D

E

F

32

General consultation skills. Now, we ask you to evaluate the student’s consultation skills by most important

categories on a scale from A (excellent) to F (insufficient).

Examination

▪ The student inquires about the patient’s reasons for coming to the visit

and his/her expectations


background


A

B

C

D

E

F

Emotions



A

B

C

D

E

F



perceptible size



A

B

C

D

E

F

Making a summary



A

B

C

D

E

F




A

B

C

D

E

F

Empathy

▪ The student expresses interest in the patient verbally


A

B

C

D

E

F

33

Contact with the patient and collecting the history

The student achieves contact with all patients easily. He/she collects history in a structured and thorough

way, taking into account the reason the patient came to the visit and does not neglect anything.

A

The student achieves contact with most patients easily. He/she collects history in a structured and thorough

way, taking into account the reason the patient came to the visit. He/she has overlooked some

circumstances, but nothing important.

B

The student does not have big difficulties in achieving contact with patient. He/she collects history in a

generally structured way. Sometimes, he/she overlooks some circumstances, but usually nothing important.

It is possible to improve his/her skills with consistent training.

C

The student has some difficulties in achieving contact with the patient. He/she collects history in not a very

structured way. Sometimes, he/she overlooks important circumstances. It is possible to improve his/her

skills with consistent training.

D

The student does not achieve contact with most patients. His/her history collecting is unstructured and

he/she overlooks important circumstances often.

E

It is hard to evaluate the student, as participation in everyday work of family doctor’s practice was

insufficient.

F

Objective examination of the patient

The student commands different patient examination methods and the indications for their use to an

excellent level and has a good overview of the theory underneath. He/she examines the patient in a

structured and thorough way, taking into account the reason the patient came to the visit and does not

neglect anything.

A

The student knows well the patient examination methods and indications for their use. He/she examines the

patient in a structured and thorough way, taking into account the reason the patient came to the visit.

He/she has overlooked some circumstances, but nothing important.

B

The student knows satisfactorily the patient examination methods and indications for their use. He/she

examines the patient generally in a structured way. Sometimes, he/she overlooks some circumstances, but

usually nothing important. It is possible to improve his/her skills with consistent training.

C

The student’s knowledge of the patient examination methods and indications for their use is sometimes

fragmentary. He/she does not examine the patient in a structured way and sometimes he/she overlooks

important circumstances. It is possible to improve his/her skills with consistent training.

D

The student’s knowledge of the patient examination methods and indications for their use is fragmentary.

He/she does not examine the patient in a structured way and he/she overlooks important circumstances

often.

E


insufficient.

F

34

Theoretical knowledge and clinical thinking

The student’s knowledge in most domains is deep and integral. If he/she does not know something, he/she

finds answers to the questions quickly and without outside help. His/her clinical thinking is systematic and

he/she presents his/her reasoning clearly and explicitly.

A

The student’s knowledge in most domains is deep and integral. There are some gaps, but he/she finds answers

to the questions within reasonable time and without outside help. His/her clinical thinking is systematic and


B

The student’s knowledge in most domains is good although there are sometimes gaps in further details.

He/she finds answers to the questions within reasonable time, needing outside help rarely. His/her clinical

thinking is systematic in general terms and he/she presents his/her reasoning comprehensibly. It is possible to

improve his/her knowledge with consistent learning.

C

The student’s knowledge in most domains is sufficient, but there are also considerable gaps. He/she needs

time to find answers to the questions and he/she needs in this outside help often. Sometimes, his/her clinical

thinking is not systematic or he/she presents his/her reasoning incomprehensibly. It is possible to improve

his/her knowledge with consistent learning.

D

The student’s knowledge in most domains is fragmental. He/she need time to find answers to the questions

and he/she needs in this outside help often. His/her clinical thinking is not systematic and he/she presents

his/her reasoning incomprehensibly.

E


insufficient.

F

Participation in the everyday work of the family doctor’s practice

The student always has correct appearance, is responsible, accurate and organized. Shows creativity and

initiative in clinical work. He/she is polite when communicating with colleagues as well as patients. He/she

knows the limits of his/her competence and does not surpass them, but asks for help from an older

colleague. During consultation, he/she presents the available data and clinical question clearly and

explicitly.

A

The student always has correct appearance, is responsible, accurate and organized. He/she is polite when

communicating with colleagues as well as patients. He/she knows the limits of his/her competence and

does not surpass them, but asks for help from older colleagues. During consultation, he/she presents the

available data and clinical question clearly and explicitly.

B

The student always has correct appearance and is responsible. He/she is polite when communicating with

colleagues as well as patients. He/she knows the limits of his/her competence and does not surpass them,

but asks for help from an older colleague.

C

The student has mostly correct appearance and is responsible. During the cycle, nonetheless, there were

situations when he/she could have behaved more politely when communicating with a colleague or a

patient. He/she knows the limits of his/her competence and mostly does not surpass them, but asks for help

from an older colleague. Further efforts are needed.

D

35


The student should be responsible regarding his/her work assignments and communicate more politely

with colleagues and patients. Further efforts are needed.

E


insufficient.

F

36

2. EMERGENCY MEDICINE

Emergency medicine practice cycle





cycle. We ask that you confirm the completing of different parts of the practice logbook with a mark in the


The student has presented 8 hospital discharge summaries yes



categories:




▪ participation in the everyday work of the department yes



Hospital and department Stamp

37


During the emergency medicine cycle, you have to write 8 hospital discharge summaries on pre-determined

bases. The topics of these hospital discharge summaries are the more frequent reasons for visits in emergency

medicine that are shown in the next table. In the same table, you can keep a record of already written hospital

discharge summaries by making marks in box E (epicrisis). When the supervisor has read your hospital

discharge summary, and is satisfied therewith, ask him/her to write his/her signature next to the box. One

hospital discharge summary can be written on one topic.

With this task, we wish to motivate you to take your time and think about the patient as a whole. Remember,

what you did and why? What is the patient’s background – why did he/she come to you? What happens with

him/her in the future? What can be learned from one or another case? We presume that you will nonetheless

have to fill the hospital’s documentation and there is no need to duplicate it.

Try to distribute your activities evenly with your supervisor. If you will leave all hospital discharge summaries

to the end of the cycle, you may not have time to focus properly and your supervisor may not have the

possibility to read them and give comprehensive feedback. For example, agree to present one hospital

discharge summary a week.

Topics of discharge summaries in emergency medicine

Allergic reaction, rash E

Dyspnoea, breathlessness E

Nausea, vomiting E

Extremity pain E

Increase of body temperature E

Muscle cramps, twitches E

Throat pain E

Hearing loss, blocked ear E

Diarrhoea E

Abdominal pain E

Hypertension E

Ear pain E

38

Cough E

Local infection E

Poisoning E

Neurological focal findings E

Weakness, fatigue E

Headache, balance disorder, dizziness E

Chest pain E

Back pain E

Arrhythmia, palpitations E

Change of consciousness, fainting E

Trauma E

Oedema of extremities, trunk, lungs E

Pain, urgency during urination E

39

Emergency medicine hospital discharge summary (epicrisis)


Triage category red orange yellow green blue

Disease history



Primary diagnosis


Further investigation plan. How do the investigation results change the approach?

Treatment

continues

at home as an

outpatient

as an

inpatient or

the patient died

40




Disease history



Primary diagnosis



Treatment

continues

at home as an

outpatient

as an

inpatient or

the patient died

41




Disease history



Primary diagnosis



Treatment

continues

at home as an

outpatient

as an

inpatient or

the patient died

42




Disease history



Primary diagnosis



Treatment

continues

at home as an

outpatient

as an

inpatient or

the patient died

43




Disease history



Primary diagnosis



Treatment

continues

at home as an

outpatient

as an

inpatient or

the patient died

44




Disease history



Primary diagnosis



Treatment

continues

at home as an

outpatient

as an

inpatient or

the patient died

45




Disease history



Primary diagnosis



Treatment

continues

at home as an

outpatient

as an

inpatient or

the patient died

46




Disease history



Primary diagnosis



Treatment

continues

at home as an

outpatient

as an

inpatient or

the patient died

47





48


49


50


We ask you to evaluate the student in four categories: (a) contact with the patient and collecting history; (b)

objective examination of the patient; (c) theoretical knowledge; and (d) participation in the everyday work of

the department. You do not have to evaluate in free form, but you can choose between predetermined

descriptions.

Remember, that not all students are and cannot be excellent to the utmost! We recommend: (a) to start with the

rating C (good); (b) think, if the student corresponds to the description, is better or worse; and (c) then move

correspondingly up or down when answering.


The student achieves contact with all patients easily. He/she collects history in a structured and

thorough way, taking into account the reason the patient came to the visit and does not neglect

anything.

A

The student achieves contact with most patients easily. He/she collects history in a structured and

thorough way, taking into account the reason the patient came to the visit. He/she has overlooked

some circumstances, but nothing important.

B

The student does not have big difficulties in achieving contact with the patient. He/she collects history

in a generally structured way. Sometimes, he/she overlooks some circumstances, but usually nothing

important. It is possible to improve his/her skills with consistent training.

C

The student has some difficulties in achieving contact with the patient. He/she collects history in a not

very structured way. Sometimes, he/she overlooks important circumstances. It is possible to improve

his/her skills with consistent training.

D



E

It is hard to evaluate the student, as participation in everyday work of the department was insufficient. F


The student commands different patient examination methods and the indications of their use to an



neglect anything.

A

The student knows well the patient examination methods and indications for their use. He/she

examines the patient in a structured and thorough way, taking into account the reason the patient came

to the visit. He/she has overlooked some circumstances, but nothing important.

B

51

The student knows the patient examination methods and indications for their use satisfactorily. He/she

examines the patient generally in a structured way. Sometimes, he/she overlooks some circumstances,

but usually nothing important. It is possible to improve his/her skills with consistent training.

C

The student’s knowledge of the patient examination methods and indications for their use is

sometimes fragmentary. He/she does not examine the patient in a structured way, and sometimes,

he/she overlooks important circumstances. It is possible to improve his/her skills with consistent

training.

D

The student’s knowledge of the patient examination methods and indications for their use is

fragmentary. He/she does not examine the patient in a structured way and he/she overlooks important

circumstances often.

E



The student knowledge in most domains is deep and integral. If he/she does not know something,

he/she finds answers to the questions quickly and without outside help. His/her clinical thinking is

systematic and he/she presents his/her reasoning clearly and explicitly.

A

The student knowledge in most domains is deep and integral. There are some gaps, but he/she finds

answers to the questions within reasonable time and without outside help. His/her clinical thinking is

systematic and he/she presents his/her reasoning clearly and explicitly.

B

The student’s knowledge in most domains is good, although there are sometimes gaps in further

details. He/she finds answers the questions within reasonable time, rarely needing outside help.

His/her clinical thinking is systematic in general terms and he/she presents his/her reasoning

comprehensibly. It is possible to improve his/her knowledge with consistent learning.

C

The student’s knowledge in most domains is sufficient, but there are also considerable gaps. He/she

needs time to find answers to the questions and he/she needs in this outside help often. Sometimes,

his/her clinical thinking is not very systematic or he/she presents his/her reasoning incomprehensibly.

It is possible to improve his/her knowledge with consistent learning.

D

The student’s knowledge in most domains is fragmental. He/she needs time to find answers to the

questions and he/she often needs outside help. His/her clinical thinking is not systematic and he/she

presents his/her reasoning incomprehensibly.

E

It is hard to evaluate the student, as participation in everyday work of the department was insufficient.

F

52

Participation in the everyday work of the department

The student always has correct appearance, is responsible, accurate and organized. Shows creativity

and initiative in clinical work. He/she is polite when communicating with colleagues as well as

patients. He/she knows the limits of his/her competence and does not surpass them, but asks for help

from older colleagues. During consultation, he/she presents the available data and clinical question

clearly and explicitly.

A

The student always has correct appearance, is responsible, accurate and organized. He/she is polite

when communicating with colleagues as well as patients. He/she knows the limits of his/her

competence and does not surpass them, but asks for help from older colleagues. During consultation,

he/she presents the available data and clinical question clearly and explicitly.

B

The student always has correct appearance and is responsible. He/she is polite when communicating

with colleagues as well as patients. He/she knows the limits of his/her competence and does not

surpass them, but asks for help from older colleagues.

C

The student has mostly correct appearance and is responsible. During the cycle, there were situations

when he/she could have behaved more politely when communicating with a colleague or patient.

He/she knows the limits of his/her competence and mostly does not surpass them, but asks for help

from older colleagues. Further efforts are needed.

D

The student should be responsible regarding his/her work assignments and communicate more

politely with colleagues and patients. Further efforts are needed.

E


53

3. INTERNAL MEDICINE

Internal medicine practice cycle




Performing practice cycle. The doctor supervising the student completes these fields at the end of the cycle. We

ask that you confirm the completing of different parts of the practice logbook with a mark in the yes box and

signature next to it.

During the practice cycle, the student participated in:

▪ in-patient work of the department

▪ out-patient consultations of the supervising doctor

▪ on-call work of the department yes




categories:








54


During the internal medicine cycle, you have to write 8 hospital discharge summaries (epicrises) on pre-

determined bases. The topics of these hospital discharge summaries are the more frequent reasons for visits

and diagnoses in internal medicine that are shown in the next table. In the same table, you can keep record of

already written hospital discharge summaries by making marks in box E (medical history). When the

supervisor has read your hospital discharge summary, and is satisfied therewith, ask him/her to write his/her

signature next to the box. One hospital discharge summary can be written on one topic.



him/her in the future? What can be learned from one or another case? We presume that you will have to fill the

hospital’s documentation and there is no need to duplicate it.





Hospital discharge summary topics in internal medicine

Reasons for coming to the visit

Nausea, vomiting, diarrhoea E

Jaundice E

Oedema of extremities, trunk, lungs E

Cough, dyspnoea, breathlessness E

Muscle cramps, twitches E

Neurological focal findings E

Headache, balance disorder, dizziness E

Chest pain E

Arrhythmia, palpitations E

Change of consciousness, fainting E

Pain, urgency during urination E

55

Specific diagnoses

Anaemia E

Bacterial meningitis, viral meningitis E

Bronchial asthma, chronic obstructive pulmonary disease E

Crohn’s disease, ulcerative colitis E

Epilepsy, febrile seizures E

Hypertension E

Hypothyroidism, hyperthyroidism E

Type I diabetes, type II diabetes E

Ischaemic stroke, haemorrhagic stroke E

Atrial fibrillation E

Pulmonary artery thrombembolism E

Chronic renal failure E

Chronic heart failure E

Lymphoma E

Hepatic cirrhosis E

Myeloma E

Osteoporosis E

Peptic ulcer, reflux disease E

Pneumonia E

Gout, crystallopathy E

Rheumatoid arthritis E

56

STEMI, NSTEMI, unstable angina pectoris E

Cystitis, pyelonephritis E

Acute glomerulonephritis E

Acute hepatitis, chronic hepatitis E

Acute leukaemia, chronic leukaemia E

57

Internal medicine hospital discharge summary (epicrisis)


Disease history



Treatment and further investigation plan. How do the investigation results change the approach?

Results of further investigations and disease course

Final diagnosis

Treatment

continues

at

home

as an

outpatient

as an inpatient in

other institution or

the patient

died

58



Disease history





Final diagnosis

Treatment

continues

at

home

as an

outpatient

as an inpatient in


the patient

died

59



Disease history





Final diagnosis

Treatment

continues

at

home

as an

outpatient

as an inpatient in


the patient

died

60



Disease history





Final diagnosis

Treatment

continues

at

home

as an

outpatient

as an inpatient in


the patient

died

61



Disease history





Final diagnosis

Treatment

continues

at

home

as an

outpatient

as an inpatient in


the patient

died

62



Disease history





Final diagnosis

Treatment

continues

at

home

as an

outpatient

as an inpatient in


the patient

died

63



Disease history





Final diagnosis

Treatment

continues

at

home

as an

outpatient

as an inpatient in


the patient

died

64



Disease history





Final diagnosis

Treatment

continues

at

home

as an

outpatient

as an inpatient in


the patient

died

65





66


67


68

3.2. Self-analysis




Self-analysis

69





descriptions.



correspondingly up or down when answering..




Introduction




visit

A

B

C

D

E

F

Repeated visit


plan



N

A

B

C

D

E

F





A

B

C

D

E

F






N

A

B

C

D

E

F

70



examination



the diagnosis


disease


N

A

B

C

D

E

F

Further approach


approaches




A

B

C

D

E

F



Examination




background


A

B

C

D

E

F

Emotions



A

B

C

D

E

F



perceptible size



A

B

C

D

E

F

Making a summary



A

B

C

D

E

F




A

B

C

D

E

F

Empathy



A

B

C

D

E

F

71




Introduction




the visit

A

B

C

D

E

F

Repeated visit


treatment plan



N

A

B

C

D

E

F





time

A

B

C

D

E

F






patient

N

A

B

C

D

E

F



examination



and the diagnosis


disease


N

A

B

C

D

E

F

Further approach


approaches




A

B

C

D

E

F

72



Examination




background


A

B

C

D

E

F

Emotions



A

B

C

D

E

F



perceptible size



A

B

C

D

E

F

Making a summary



A

B

C

D

E

F




A

B

C

D

E

F

Empathy



A

B

C

D

E

F

73




A




B




C




D



E


insufficient.

F





neglect anything.

A




B




C




D



often.

E


insufficient.

F

74





A




B





C





D




E


insufficient.

F






explicitly.

A





B




C





D

75




E


insufficient.

F

76

4. SURGERY

Surgery practice cycle





cycle. We ask that you confirm the completing of different parts of the practice logbook with a mark in the


During the practice cycle the student participated in:

▪ in-patient work of the department

▪ out-patient consultations of the supervising doctor

▪ on-call work of the department yes




categories:








77


During the surgery cycle, you have to write 8 hospital discharge summaries (epicrises) on pre-determined

bases. The topics of these hospital discharge summaries are the more frequent reasons for visits and diagnoses

in surgery that are shown in the next table. In the same table, you can keep record of already written hospital

discharge summaries by making marks in box E (medical history). When the supervisor has read your hospital

discharge summary, and is satisfied therewith, ask him/her to write his/her signature next to the box. One

hospital discharge summary can be written on one topic.



him/her in the future? What can be learned from one or another case? We presume that you will have to fill the

hospital’s documentation and there is no need to duplicate it.





Hospital discharge summary topics in surgery

Appendicitis E

Surgical disease of gallbladder, bile ducts E

Ileus E

Gastrointestinal haemorrhage E

Complication of peptic ulcer E

Diverticulitis E

Peritonitis E

Abdominal trauma E

Mesenteric ischaemia E

Oesophagus disease E

Benign disease of anus and rectum E

Infection of soft tissue, diabetic foot E

78

Atherosclerosis of peripheral arteries E

Surgical disease of urinary tract, prostate E

Hernia E

Malignant tumour E

Bone fracture requiring surgical treatment E

Uterine myoma E

Endometriosis E

Inflammation of minor pelvis E

79

Surgery hospital discharge summary


Disease history



Treatment and further investigation plan. Substantiate, why you choose conservative or surgical treatment!


Final diagnosis

Treatment

continues

at

home

as an

outpatient

as an inpatient in


the patient

died

80



Disease history





Final diagnosis

Treatment

continues

at

home

as an

outpatient

as an inpatient in


the patient

died

81



Disease history





Final diagnosis

Treatment

continues

at

home

as an

outpatient

as an inpatient in


the patient

died

82



Disease history





Final diagnosis

Treatment

continues

at

home

as an

outpatient

as an inpatient in


the patient

died

83



Disease history





Final diagnosis

Treatment

continues

at

home

as an

outpatient

as an inpatient in


the patient

died

84



Disease history





Final diagnosis

Treatment

continues

at

home

as an

outpatient

as an inpatient in


the patient

died

85



Disease history





Final diagnosis

Treatment

continues

at

home

as an

outpatient

as an inpatient in


the patient

died

86



Disease history





Final diagnosis

Treatment

continues

at

home

as an

outpatient

as an inpatient in


the patient

died

87





88


89


90

4.2. Self-analysis




Self-analysis

91





descriptions.



correspondingly up or down when answering..




Introduction




visit

A

B

C

D

E

F

Repeated visit


plan



N

A

B

C

D

E

F





A

B

C

D

E

F






N

A

B

C

D

E

F

92



examination



the diagnosis


disease


N

A

B

C

D

E

F

Further approach


approaches




A

B

C

D

E

F



Examination




background


A

B

C

D

E

F

Emotions



A

B

C

D

E

F



perceptible size



A

B

C

D

E

F

Making a summary



A

B

C

D

E

F




A

B

C

D

E

F

Empathy



A

B

C

D

E

F

93




Introduction




the visit

A

B

C

D

E

F

Repeated visit


treatment plan



N

A

B

C

D

E

F





time

A

B

C

D

E

F






patient

N

A

B

C

D

E

F



examination



and the diagnosis


disease


N

A

B

C

D

E

F

Further approach


approaches




A

B

C

D

E

F

94



Examination




background


A

B

C

D

E

F

Emotions



A

B

C

D

E

F



perceptible size



A

B

C

D

E

F

Making a summary



A

B

C

D

E

F




A

B

C

D

E

F

Empathy



A

B

C

D

E

F

95




A




B




C




D



E


insufficient.

F





neglect anything.

A




B




C




D



often.

E


insufficient.

F

96





A




B





C





D




E


insufficient.

F






explicitly.

A





B




C





D

97




E


insufficient.

F

98

5. OPTIONAL CYCLE

Optional cycle




Performing practice cycle. The student’s supervisor completes these fields at the end of the cycle. We ask

that you confirm the completing of different parts of the practice logbook with a mark in the yes box and

signature next to it.


I have given an assessment of the student’s work during the practice cycle yes

Supervisor’s data. The student’s supervisor completes these fields at the end of the cycle. The doctor’s

code and stamp are required only if the practice cycle was performed in a hospital or family doctor’s

practice.


Place of performing the optional cycle Stamp

99

5.1. Self-analysis




Self-analysis

100


We ask you to describe the student you supervised in free form. Questions to proceed from: (a) his/her

relevant theoretical knowledge and how well he/she was able to implement this; (b) what was his/her attitude

to his/her everyday tasks; and (c) is there anything because of what you would like to bring him/her into

spotlight.

Supervisor’s assessment

101

PRACTICAL SKILLS

In the next tables, 72 practical skills are listed by topics that you should develop during the practice. Of these,

36 are mandatory – you will recognise them as only they have a box N (has shown to the supervisor) and

next to it the place for the supervisor’s signature. At the end of the practice, all these skills should have a mark

in the box N and supervisor’s signature next to it.

Other skills are those that you should draw your attention to by our opinion, but nothing happens if you do not

have enough time. These have boxed O (observed), P (performed by him-/herself) and S (shown to the

supervisor). Make a mark, if you can try something and observe your development!

Do not be afraid to tell your supervisor if you have not performed some of these activities before! We

encourage you to think in your head what an activity consists of with the help of literature and videos if

required before we ask – so the learning goes faster. Try to distribute your activities evenly – if you leave the

presentation of all your practical skills to the end of the last cycle, it will need a lot of time from you and your

supervisor.

It is your choice during which cycle you will present your skills, but try to use common sense: for example,

counselling activity is best practiced during the family medicine cycle, at the same time clinical death could

be most probably encountered during emergency medicine or internal medicine cycles.

In case of some activities, it may be not possible to show them to the supervisor during the practice – here, we

think about skills associated for example with a patient in critical condition. If it is so, do not worry – describe

your activities to the supervisor orally. In addition, the supervisor may mark the activity as performed, if

he/she has seen you performing it repeatedly during the practice.


The supervisor evaluates your general history collection and objective examination skills at the end of each

cycle. Here are some aspects of objective examination of the patient that we think must be especially

emphasised and shown to the supervisor at least once during the practice.

1 Digital rectal palpation O P S

2 Performing gynaecological examination O P S

3 Objective examination of infant and child S

4 Objective examination of nose, ear and throat S

5 Performing examination of breasts O P S

102

Manual manipulations

When showing manual manipulations you should be ready to explain: (a) what are general indications of

this manipulation and why it is indicated in this patient; (b) what are general contraindications of this

manipulation; and (c) what are possible complications of this manipulation

6 Placement of artery cannula O P S

7 Puncturing an artery O P S

8 Ascites puncturing O P S

9 Performing electrocardiographic investigation S

10 Placement and changing of epicystostoma O P S

11 Determination of glucose concentration in capillary

blood

O P S

12 Evaluation of wound healing and removal of sutures S

13 Preparation of infusion system S

14 Performing intra-, subcutaneous and intramuscular injection S

15 Performing local anaesthesia O P S

16 Rinsing of acoustic meatus O P S

17 Puncturing a joint O P S

18 Performing lumbar puncture O P S

19 Replacement of joint luxation O P S

20 Immobilisation of bone fracture O P S

21 Placement of nasogastric tube and gastric lavage O P S

22 Superficial abscess opening and drain placement S

23 Cleaning, bandaging and suturing a superficial wound S

103

24 Removal of superficial foreign body S

25 Puncturing pleural effusion O P S

26 Placement of bladder catheter to man and woman S

27 Removal of finger and toe nail O P S

28 Placement of venous cannula S

29 Puncturing a vein S

30 Blood pressure measurement S

Interpreting investigations and analyses

Here, you must be able to explain: (a) what are general indications of this investigation or analysis and why

it is indicated in this patient; (b) what are possible factors influencing the result of investigation or analysis;

and (c) how does this result influence further approach to the patient. There is no need to know the reference

limits of analyses by heart.

31 Assessment of the composition of ascites and pleural

fluid

O P S

32 Interpreting electrocardiographic investigation S

33 Assessment of electrolytes, acid-base balance and blood gases S

34 Interpreting the investigations of pulmonary function O P S

35 Assessment of the composition of cerebrospinal fluid O P S

36 Assessment of the function of liver, bile ducts and pancreas S

37 Assessment of renal function S

38 Assessment of the patient’s alcohol behaviour

(AUDIT)

O P S

39 Assessment of the patient’s general emotional status

(EEK)

O P S

104

40 Assessment of the patient’s general cognitive status

(MMSE)

O P S

41 Interpreting computer tomographic investigation of

head

O P S

42 Interpreting chest x-ray investigation S

43 Assessment of heart failure and myocardial damage S

44 Interpreting urine test strip analysis S

45 Assessment of field of view, visual acuity and colour

perception

O P S

46 Interpreting blood count, leukogram and red blood indices S

105

Approach to patient in critical condition

Showing these skills to the supervisor is mandatory and probably needs no justification. Here, you must also

know the doses of the medicines – do not worry, there are not many of them! These skills are most

appropriate to be practised and shown during emergency medicine or internal medicine practice.

47 Approach to patient with bradycardia (ACLS) S

48 Approach to patient without pulse (ACLS) S

49 Determining clinical death S

50 Assessment of patient’s consciousness (GCS) S

51 Approach to patient with angina pectoris S

52 Approach to patient with shock (ACLS) S

53 Approach to patient with tachycardia (ACLS) S

Treatment initiation and monitoring

Here, you must know: (a) what medicines you start with; (b) what characteristics you use to evaluate the

patient’s treatment response; and (c) how would be most reasonable to make treatment more effective.

Doses of medicines would be reasonable to know by heart for anticoagulant treatment, insulin treatment and

pain treatment.

54 Anticoagulant treatment initiation and monitoring O P S

55 Hypertension treatment initiation and monitoring S

56 Type II diabetes treatment initiation and monitoring S

57 Infection treatment initiation and monitoring S

58 Insulin treatment initiation and monitoring O P S

59 Pain treatment initiation and monitoring S

106

Medical documentation

It is important to know about the documentation: (a) to whom and why the document is directed; and (b)

what are most important requirements for it.

60 Drawing up health certificate for a patient S

61 Drawing up certificate of incapacity for work for a patient S

62 Referral of a patient to a care facility O P S

63 Compiling a treatment invoice for Health Insurance

Fund

O P S

64 Writing prescription for medicine and medical device S

65 Drawing up referral to specialist’s visit or investigation S

66 Drawing up referral to patho-anatomical autopsy O P S

67 Drawing up death certificate O P S

Counselling of the patient

Here you must: (a) be able to assess the patient’s readiness for counselling; (b) know the possibilities and

risks of counselling activities in general and for specific patient; and (c) know the basics of motivating

interview. These skills are most appropriate to be practised and shown during family medicine practice

cycle.

68 Counselling of the patient regarding alcohol behaviour O P S

69 Counselling of the patient regarding movement O P S

70 Counselling of the patient regarding giving up

smoking

O P S

71 Counselling of the patient regarding diet O P S

72 Counselling of the patient regarding vaccination O P S

Documents

CLINICAL PRACTICE LOGBOOK - Tartu Ülikooli ... addition to clinical everyday work the student must practice the practical skills required for a doctor and participate in seminars