SP SPA 1 (History) (SPA 1) 1. Item 4: Eliciting the Narrative Thread ( ) 5. The Learner encouraged and let the patient talk about the patient's problem(s). The Learner did not stop the patient or introduce new information. ( ) 4 ( ) 3. The Learner began to let the patient tell the patient’s story, but either interrupted with focused questions or introduced new information. ( ) 2 ( ) 1. The Learner failed to let the patient tell the patient’s story. OR The Learner set the pace with a Q&A style, as opposed to a conversational style. 2. Item 5: Timeline ( ) 5. The Learner obtained sufficient information so that a chronology of the chief complaint and history of the present illness can be established. The chronology of any associated symptoms is also established. ( ) 4 ( ) 3. The Learner obtained some of the information necessary to establish a chronology. The Learner failed to establish a chronology for any associated symptoms. ( ) 2 ( ) 1. The Learner failed to obtain information necessary to establish a chronology. 3. Item 6: Questioning of Questions (edited) ( ) 5. The Learner begins information gathering with more than one open-ended question. This is followed up by more specific or direct questions. No poor question types are used. ( ) 4 ( ) 3. The Learner often failed to begin a line of inquiry with open-ended questions, but rather employed specific or direct questions to gather information. OR ( ) 2 ( ) 1. The Learner asked many why questions, multiple questions, or leading questions.
The Learner used a few leading, why, or multiple questions. 4. Item 21: Closure ( ) 5. At the end of the interview the Learner clearly specifies the future plans as to What the Learner will do (make referrals, order tests), What the patient will do (make diet changes, go to physical therapy) and When (the time of the next communication or appointment). ( ) 4 ( ) 3. At the end of the interview, the Learner partially detailed the plans for the future. ( ) 2 ( ) 1. At the end of the interview, the Learner failed to specify the plans for the future and the patient left the interview without a sense of what to expect. There was no closure whatsoever. 5. Comments: SP SPA 2 (Physical Exam) (SPA 2) 6. Learner is cleansing hands when he/she enters the room or tells you they have cleaned their hands or washes hands at any point prior to the physical exam ( ) Yes ( ) No 7. Examines you appropriately (not through gown or clothing). ( ) Yes ( ) No 8. Drapes appropriately and protects modesty. ( ) Yes ( ) No
9. Learner describes physical exam or procedures to you ( ) Yes ( ) No 10. Learner considers your comfort during exam ( ) Yes ( ) No 11. Comments: SP SPA 7 (Communication) (SPA 7) 12. Item 1: Opening ( ) 5. The Learner opened by introducing themselves (including their last name), clarifying their role, and greeting the patient. The greeting should include good eye contact and a smile. ( ) 4 ( ) 3. The Learner’s introduction is missing a critical element. ( ) 2 ( ) 1. There is no introduction.
13. Item 8: Lack of Jargon ( ) 5. The interviewer asks questions and provides information in language that is easily understood; content is free of difficult medical terms and jargon. Words are IMMEDIATELY DEFINED for the patient. Language is used that is appropriate to the patient's level of education. ( ) 4 ( ) 3. The Learner occasionally used medical jargon during the interview and failed to define the medical terms for the patient unless specifically requested to do so by the patient. ( ) 2 ( ) 1. The Learner used difficult medical terms and jargon throughout the interview. 14. Item 13: Verbal Facilitation Skills ( ) 5. The Learner used facilitation skills throughout the interview. Verbal encouragement, use of short statements and echoing were used when appropriate. ( ) 4 ( ) 3. The Learner used some facilitative skills, but not consistently or at appropriate times. Verbal encouragement could have been used more effectively. ( ) 2 ( ) 1. The Learner failed to use facilitative skills to encourage the patient to tell his story. 15. Item 14: Non-Verbal Facilitation Skills ( ) 5. The Learner put the patient at ease and facilitated communication by using good eye contact; relaxed, ( ) 4 ( ) 3. The Learner made some use of facilitative techniques, but could be more consistent in that ( ) 2 ( ) 1. The Learner made no attempt to put the patient at ease. The Learner’s body language was negative or closed. Annoying
17. Item 16: Encouragement of Questions ( ) 5. The Learner encouraged the patient to ask questions about the topics discussed. The Learner also gives the patient the opportunity to bring up additional topics or points not covered in the interview (e.g., "We've discussed many things. Are there any questions you might like to ask concerning your problem?" Is there anything else at all you'd like to talk about?") This is particularly important at the end of the interview. ( ) 4 ( ) 3. The Learner provided the patient with the opportunity to discuss any additional points or ask any additional questions, but neither encouraged nor discouraged the patient. ( ) 2 ( ) 1. The Learner failed to provide the patient with the opportunity to ask questions or discuss additional points. The Learner may have discouraged questions from the patient. 18. Item 18 - Patient Education and Understanding ( ) 5. The Learner used deliberate techniques to determine the patient’s understanding of the information given to the patient during the interview, including the diagnosis. These techniques included asking the patient to repeat ( ) 4 ( ) 3. The Learner asked the patient if he understood the given information, but did not use a deliberate technique to check the patient’s understanding. The Learner made some attempt to check the patient’s ( ) 2 ( ) 1. The Learner failed to assess the patient’s level of understanding and did not effectively correct misunderstandings when it was evident such a situation existed. AND/OR The Learner completely failed to address the issue of patient education and understanding.
HPI: Alleviating factors: (patient must volunteer or learner must ask about relief with rest to get a "yes") ( ) No 33. HPI:Timing ( ) Yes ( ) No 34. HPI: Severity ( ) Yes ( ) No 35. HPI: History of this pain before? ( ) Yes ( ) No 36. HPI: Risk factors for coronary disease (HTN, DM, hyperlipidemia) ( ) Yes ( ) No 37. PMH: Past medical history ( ) Yes ( ) No 38. PMH: Prescription Medications? ( ) Yes ( ) No 39. PMH: OTC Medications? ( ) Yes ( ) No 40. PMH: Medication Allergies? ( ) Yes ( ) No 41. ( ) Yes
FH: Specifically asks about family history of heart disease or family risk factors (DM, HTN, hyperlipidemia, etc.) (either question will get the student a "yes") ( ) No 42. SH: Smoking Hx? ( ) Yes ( ) No 43. SH: Recreational drug use? ( ) Yes ( ) No 44. ROS: Pulmonary: Dyspnea? ( ) Yes ( ) No 45. ROS: CV: Palpitations? ( ) Yes ( ) No 46. ROS: GI: Nausea or vomiting? ( ) Yes ( ) No 47. ROS: General: Sweating or cold/clammy feelings ( ) Yes ( ) No 48. Comments:
55. CV: Assess Jugular Venous Pulsation ( ) Correct Technique ( ) Incorrect Technique ( ) Not Done 56. CV: Palpates apical impulse ( ) Correct Technique ( ) Incorrect Technique ( ) Not Done 57. CV: Auscultates heart with the diaphragm in the correct 4 listening areas with patient supine (laying down). ( ) Correct Technique ( ) Incorrect Technique ( ) Not Done 58. CV: Auscultates heart with the bell in the mitral and tricuspid area. ( ) Correct Technique ( ) Incorrect Technique ( ) Not Done 59. CV: Palpates pulses in upper extremities bilaterally. ( ) Correct Technique ( ) Incorrect Technique ( ) Not Done
60. CV: Palpates pulses in lower extremities bilaterally. ( ) Correct Technique ( ) Incorrect Technique ( ) Not Done 61. CV: Checks for pedal edema by pressing on the patient's shin. ( ) Correct Technique ( ) Incorrect Technique ( ) Not Done 62. Abdomen: Palpation light and deep in all 4 quadrants with knees flexed. ( ) Correct Technique ( ) Incorrect Technique ( ) Not Done 63. COMMENTS: FON SPA 8 (Difficult Communication) (SPA 8) 64. Driving Safety Conversation ( ) Addressed driving safety appropriately. ( ) Addressed driving safety adequately. ( ) Did not appropriately address driving safety. Concerning Student Performance (CSP) 65. Do you have concerns about this student's performance that have NOT been represented by any other checklist item? ( ) Yes (comments required) ( ) Possibly (comments required) ( ) No 66. Comments: Bottom of Form