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:
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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!
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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.
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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.
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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
731 8507
Heli Tähepõld
Family medicine specialty supervisor
731 9215
Aleksander Sipria
Emergency medicine specialty supervisor
731 8414
Mai Rosenberg
Internal medicine specialty supervisor
731 8276
Margot Peetsalu
Surgery specialty supervisor
731 8232
Kätlin Puksand
SAMF practice workgroup
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
462 2783
East Tallinn Central Hospital
Ravi tn 18, Tallinn
Anne Sirge
606 7806, 5635 3445
Ida-Viru Central Hospital
Ilmajaama tn 12/14, Kohtla-Järve
Aime Keis
339 5064, 5699 1110
Järvamaa Hospital
Tiigi tn 8, Paide
Andres Müürsepp
384 8100
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Kuressaare Hospital
Aia tn 25, Kuressaare
Viktor Sarapuu
452 0002
Southern-Estonian Hospital
Meegomäe küla, Võru vald
Agnes Aart
786 8502, 517 5662
Western Tallinn Central Hospital
Paldiski mnt 68, Tallinn
Merike Paat
666 5320, 515 9496
Läänemaa Hospital
Vaba 6, Haapsalu
Tõnis Siir
Narva Hospital
Haigla tn 7, Narva
Pille Letjuka
357 1820, 5645 7709
North Estonia Medical Centre
Sütiste tee 19, Tallinn
Andrus Remmelgas
617 1525
Põlva Hospital
Uus tn 2, Põlva
Koit Jostov
Pärnu Hospital
Ristiku 1, Pärnu
Veiko Vahula
447 3103
Rakvere Hospital
Lõuna põik 1, Rakvere
Sirje Kiisküla
322 9021, 517 4169
Rapla County Hospital
Alu tee 1, Rapla
Aivar Tooming
5599 5797
Tallinn Children’s Hospital
Tervise 28, Tallinn
Mari Laan
Tartu University Hospital
L. Puusepa 8, Tartu
Clinical practice specialty supervisors are the
practice coordinators in the Tartu University
Hospital
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Valga Hospital
Peetri 2, Valga
Kristel Kivisild
766 5202
Viljandi Hospital
Pärna tee 3, Jämejala küla, Viljandi vald
Enno Kase
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
Approach to acute disease C
Approach to acute disease 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
Reason for coming to the visit
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
Reason for coming to the visit
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.
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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
Objective findings. Also, add the results of relevant analyses and investigations.
Differential diagnosis
Primary diagnosis
Initial approach. Substantiate briefly!
Further approach. If and when do you plan the next contact?
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Approach to chronic disease
Reason for coming to the visit
More important chronic diseases and their duration. If possible, note the risk level of complications or
mortality.
Objective findings, results of relevant analyses and investigations. Do the chronic diseases have
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.
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Approach to chronic disease
Reason for coming to the visit
More important chronic diseases and their duration. If possible, note the risk level of complications or
mortality.
Objective findings, results of relevant analyses and investigations. Do the chronic diseases have
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.
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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!
Reason for coming to the visit
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?
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Phone consultation
Reason for coming to the visit
Disease history
Differential diagnosis
Primary diagnosis
Initial approach. Substantiate briefly!
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
Reason for coming to the visit
Disease history
Objective findings. Add the results of relevant analyses and investigations.
Differential diagnosis
Taking into account the reason for coming to the visit, what could be the signs of danger and what could
these indicate?
Primary diagnosis
Initial approach. Substantiate briefly!
Further approach. If and when do you plan the next contact?
23
Approach to acute disease
Reason for coming to the visit
Disease history
Objective findings. Add the results of relevant analyses and investigations.
Differential diagnosis
Taking into account the reason for coming to the visit, what could be the signs of danger and what could
these indicate?
Primary diagnosis
Initial approach. Substantiate briefly!
Further approach. If and when do you plan the next contact?
24
Approach to acute disease
Reason for coming to the visit
Disease history
Objective findings. Add the results of relevant analyses and investigations.
Differential diagnosis
Taking into account the reason for coming to the visit, what could be the signs of danger and what could
these indicate?
Primary diagnosis
Initial approach. Substantiate briefly!
Further approach. If and when do you plan the next contact?
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
Reason for coming to the visit, short history Interesting or informative aspect
27
Reason for coming to the visit, short history Interesting or informative aspect
28
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
▪ The student asks the patient’s opinion
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
▪ The student checks if the patient understands the 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 gives the patient a chance to talk
▪ 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
▪ 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
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
▪ The student asks the patient’s opinion
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
▪ 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
▪ The student checks if the patient understands the 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 in the patient verbally
▪ The student expresses interest with tone, gestures and eye contact
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
It is hard to evaluate the student, as participation in everyday work of family doctor’s practice was
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
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 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
It is hard to evaluate the student, as participation in everyday work of family doctor’s practice was
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
Participation in the everyday work of the family doctor’s practice
The student should be responsible regarding his/her work assignments and communicate more politely
with colleagues and patients. Further efforts are needed.
E
It is hard to evaluate the student, as participation in everyday work of family doctor’s practice was
insufficient.
F
36
2. EMERGENCY MEDICINE
Emergency 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 completing of different parts of the practice logbook with a mark in the
yes box and signature next to it.
The student has presented 8 hospital discharge summaries yes
The student has presented self-analysis 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 department 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
Hospital and department Stamp
37
2.1. Work with patients
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)
Reason for coming to the visit
Triage category red orange yellow green blue
Disease history
Objective findings. Add the results of relevant analyses and investigations.
Differential diagnosis
Primary diagnosis
Initial approach. Substantiate briefly!
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
Emergency medicine hospital discharge summary (epicrisis)
Reason for coming to the visit
Triage category red orange yellow green blue
Disease history
Objective findings. Add the results of relevant analyses and investigations.
Differential diagnosis
Primary diagnosis
Initial approach. Substantiate briefly!
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
41
Emergency medicine hospital discharge summary (epicrisis)
Reason for coming to the visit
Triage category red orange yellow green blue
Disease history
Objective findings. Add the results of relevant analyses and investigations.
Differential diagnosis
Primary diagnosis
Initial approach. Substantiate briefly!
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
42
Emergency medicine hospital discharge summary (epicrisis)
Reason for coming to the visit
Triage category red orange yellow green blue
Disease history
Objective findings. Add the results of relevant analyses and investigations.
Differential diagnosis
Primary diagnosis
Initial approach. Substantiate briefly!
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
43
Emergency medicine hospital discharge summary (epicrisis)
Reason for coming to the visit
Triage category red orange yellow green blue
Disease history
Objective findings. Add the results of relevant analyses and investigations.
Differential diagnosis
Primary diagnosis
Initial approach. Substantiate briefly!
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
44
Emergency medicine hospital discharge summary (epicrisis)
Reason for coming to the visit
Triage category red orange yellow green blue
Disease history
Objective findings. Add the results of relevant analyses and investigations.
Differential diagnosis
Primary diagnosis
Initial approach. Substantiate briefly!
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
45
Emergency medicine hospital discharge summary (epicrisis)
Reason for coming to the visit
Triage category red orange yellow green blue
Disease history
Objective findings. Add the results of relevant analyses and investigations.
Differential diagnosis
Primary diagnosis
Initial approach. Substantiate briefly!
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
46
Emergency medicine hospital discharge summary (epicrisis)
Reason for coming to the visit
Triage category red orange yellow green blue
Disease history
Objective findings. Add the results of relevant analyses and investigations.
Differential diagnosis
Primary diagnosis
Initial approach. Substantiate briefly!
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
47
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
48
Reason for coming to the visit, short history Interesting or informative aspect
49
Reason for coming to the visit, short history Interesting or informative aspect
50
2.2. Supervisor’s assessment
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.
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 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
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 the department was insufficient. F
Objective examination of the patient
The student commands different patient examination methods and the indications of 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
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
It is hard to evaluate the student, as participation in everyday work of the department was insufficient. F
Theoretical knowledge and clinical thinking
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
It is hard to evaluate the student, as participation in everyday work of the department was insufficient. F
53
3. INTERNAL MEDICINE
Internal 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 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
The student has presented 8 hospital discharge summaries yes
The student has presented self-analysis 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 department 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
Hospital and department Stamp
54
3.1. Work with patients
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.
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 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.
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)
Reason for coming to the visit
Disease history
Objective findings. Also, add the results of relevant analyses and investigations.
Differential diagnosis
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
Internal medicine hospital discharge summary (epicrisis)
Reason for coming to the visit
Disease history
Objective findings. Also, add the results of relevant analyses and investigations.
Differential diagnosis
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
59
Internal medicine hospital discharge summary (epicrisis)
Reason for coming to the visit
Disease history
Objective findings. Also, add the results of relevant analyses and investigations.
Differential diagnosis
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
60
Internal medicine hospital discharge summary (epicrisis)
Reason for coming to the visit
Disease history
Objective findings. Also, add the results of relevant analyses and investigations.
Differential diagnosis
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
61
Internal medicine hospital discharge summary (epicrisis)
Reason for coming to the visit
Disease history
Objective findings. Also, add the results of relevant analyses and investigations.
Differential diagnosis
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
62
Internal medicine hospital discharge summary (epicrisis)
Reason for coming to the visit
Disease history
Objective findings. Also, add the results of relevant analyses and investigations.
Differential diagnosis
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
63
Internal medicine hospital discharge summary (epicrisis)
Reason for coming to the visit
Disease history
Objective findings. Also, add the results of relevant analyses and investigations.
Differential diagnosis
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
64
Internal medicine hospital discharge summary (epicrisis)
Reason for coming to the visit
Disease history
Objective findings. Also, add the results of relevant analyses and investigations.
Differential diagnosis
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
65
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
66
Reason for coming to the visit, short history Interesting or informative aspect
67
Reason for coming to the visit, short history Interesting or informative aspect
68
3.2. 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
69
3.3. Supervisor’s assessment
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’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
70
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
▪ The student asks the patient’s opinion
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
▪ The student checks if the patient understands the 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
71
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 gives the patient a chance to talk
▪ 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
▪ 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
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
▪ The student asks the patient’s opinion
A
B
C
D
E
F
72
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
▪ The student checks if the patient understands the 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 in the patient verbally
▪ The student expresses interest with tone, gestures and eye contact
A
B
C
D
E
F
73
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
It is hard to evaluate the student, as participation in everyday work of family doctor’s practice was
insufficient.
F
74
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
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 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
It is hard to evaluate the student, as participation in everyday work of family doctor’s practice was
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
75
Participation in the everyday work of the family doctor’s practice
The student should be responsible regarding his/her work assignments and communicate more politely
with colleagues and patients. Further efforts are needed.
E
It is hard to evaluate the student, as participation in everyday work of family doctor’s practice was
insufficient.
F
76
4. SURGERY
Surgery 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 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
The student has presented 8 hospital discharge summaries yes
The student has presented self-analysis 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 department 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
Hospital and department Stamp
77
4.1. Work with patients
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.
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 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.
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
Reason for coming to the visit
Disease history
Objective findings. Also, add the results of relevant analyses and investigations.
Differential diagnosis
Treatment and further investigation plan. Substantiate, why you choose conservative or surgical treatment!
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
80
Surgery hospital discharge summary
Reason for coming to the visit
Disease history
Objective findings. Also, add the results of relevant analyses and investigations.
Differential diagnosis
Treatment and further investigation plan. Substantiate, why you choose conservative or surgical treatment!
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
81
Surgery hospital discharge summary
Reason for coming to the visit
Disease history
Objective findings. Also, add the results of relevant analyses and investigations.
Differential diagnosis
Treatment and further investigation plan. Substantiate, why you choose conservative or surgical treatment!
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
82
Surgery hospital discharge summary
Reason for coming to the visit
Disease history
Objective findings. Also, add the results of relevant analyses and investigations.
Differential diagnosis
Treatment and further investigation plan. Substantiate, why you choose conservative or surgical treatment!
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
83
Surgery hospital discharge summary
Reason for coming to the visit
Disease history
Objective findings. Also, add the results of relevant analyses and investigations.
Differential diagnosis
Treatment and further investigation plan. Substantiate, why you choose conservative or surgical treatment!
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
84
Surgery hospital discharge summary
Reason for coming to the visit
Disease history
Objective findings. Also, add the results of relevant analyses and investigations.
Differential diagnosis
Treatment and further investigation plan. Substantiate, why you choose conservative or surgical treatment!
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
85
Surgery hospital discharge summary
Reason for coming to the visit
Disease history
Objective findings. Also, add the results of relevant analyses and investigations.
Differential diagnosis
Treatment and further investigation plan. Substantiate, why you choose conservative or surgical treatment!
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
86
Surgery hospital discharge summary
Reason for coming to the visit
Disease history
Objective findings. Also, add the results of relevant analyses and investigations.
Differential diagnosis
Treatment and further investigation plan. Substantiate, why you choose conservative or surgical treatment!
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
87
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
88
Reason for coming to the visit, short history Interesting or informative aspect
89
Reason for coming to the visit, short history Interesting or informative aspect
90
4.2. 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
91
4.3. Supervisor’s assessment
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’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
92
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
▪ The student asks the patient’s opinion
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
▪ The student checks if the patient understands the 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
93
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 gives the patient a chance to talk
▪ 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
▪ 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
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
▪ The student asks the patient’s opinion
A
B
C
D
E
F
94
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
▪ The student checks if the patient understands the 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 in the patient verbally
▪ The student expresses interest with tone, gestures and eye contact
A
B
C
D
E
F
95
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
It is hard to evaluate the student, as participation in everyday work of family doctor’s practice was
insufficient.
F
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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
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 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
It is hard to evaluate the student, as participation in everyday work of family doctor’s practice was
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
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Participation in the everyday work of the family doctor’s practice
The student should be responsible regarding his/her work assignments and communicate more politely
with colleagues and patients. Further efforts are needed.
E
It is hard to evaluate the student, as participation in everyday work of family doctor’s practice was
insufficient.
F
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5. OPTIONAL CYCLE
Optional 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 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.
The student has presented self-analysis yes
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.
First and last name Doctor’s code
Place of performing the optional cycle Stamp
99
5.1. 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
100
5.2. Supervisor’s assessment
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.
Objective examination of the patient
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
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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
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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
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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
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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
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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