Jenny Jones v2017 (H&P & weight loss) SP SP SPA 1 (History) (SPA 1) 1. Item 4: Eliciting the Narrative Thread ( ) 5. The Learner encouraged and let the patient talk 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 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 ( ) 4 ( ) 3. The Learner obtained some of the information necessary to ( ) 2 ( ) 1. The Learner failed to obtain information necessary to establish a chronology.
of any associated symptoms is also established. establish a chronology. The Learner failed to establish a chronology for any associated symptoms. 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 ( ) 2 ( ) 1. The Learner asked many why questions, multiple questions, or leading questions.
gather information. OR 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.
10. 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.
11. 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 for the patient unless specifically requested to do so by the patient. ( ) 2 ( ) 1. The Learner used difficult medical and jargon throughout the interview.
12. Item 13: Verbal 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. on
13. Item 14: Skills ( ) 5. The Learner put the patient at ease and facilitated communication by using good eye contact; relaxed, open body language; and appropriate facial expressions; and by eliminating physical barriers. Physical contact was made with the patient, as appropriate. ( ) 4 ( ) 3. The Learner made some use of facilitative techniques, but could be more consistent in that one or two techniques were not used effectively. A physical barrier was present. ( ) 2 ( ) 1. The Learner made no attempt to put the patient at ease. The Learner’s body language was negative or closed. Annoying mannerisms (foot or pencil tapping) intruded the interview. Eye contact was not attempted or was uncomfortable. on
Student of Concern (SOC) 18. Do you have concerns this student's performance that have NOT been represented by any other checklist item? ( ) Yes (comments required) ( ) Possibly (comments required) ( ) No, there are no concerns not reflected the checklists. 19. Comments: Faculty Observation and Narrative FON SPA 1 History (SPA 1)
20. Establishes or confirms the complaint or reason for the visit. ( ) Yes ( ) No 21. Location of pain ( ) Yes ( ) No 22. Radiation of pain ( ) Yes ( ) No 23. Other symptoms associated with the pain: ( ) Yes ( ) No 24. Character of pain. ( ) Yes ( ) No 25. Alleviating factors. ( ) Yes ( ) No 26. Aggravating factors. ( ) Yes ( ) No 27. Timing of pain. ( ) Yes ( ) No 28. Precipitant or environment/context in which pain occurs. ( ) Yes ( ) No
30. History of this pain before ( ) Yes ( ) No 31. Past medical history ( ) Yes ( ) No 32. Past surgical/ob history ( ) Yes ( ) No 33. Prescription Medications ( ) Yes ( ) No 34. OTC medications ( ) Yes ( ) No 35. ( ) ( )
Scoring for ROS Student must ask at least 1 question for each system to score "yes." 50. General symptoms ( ) Yes ( ) No 51. HEENT ( ) Yes ( ) No 52. Endocrine system ( ) Yes ( ) No
65. CN II & III: (Optic & Oculomotor): direct and consensual pupil exam ( ) Correct Technique ( ) Incorrect Technique ( ) Not 66. Performs fundoscopic examination. ( ) Correct Technique ( ) Incorrect Technique ( ) Not
CN VIII: (Acoustic): Checks hearing by finger rub. Must test each ear separately. Correct Technique Incorrect Technique Not 70. Performs otoscopic examination. ( ) Correct Technique ( ) Incorrect Technique ( ) Not 71. Examines nose by using otoscope to visualize septum, nares, turbinates. ( ) Correct Technique ( ) Incorrect Technique ( ) Not 72. Palpates the frontal and maxillary sinuses. ( ) Correct Technique ( ) Incorrect Technique ( ) Not 73. Examines oropharynx. ( ) Correct Technique ( ) Incorrect Technique ( ) Not 74. CN IX & X: (Glossopharyngeal and Vagus): palatal elevation ( ) Correct Technique ( ) Incorrect Technique ( ) Not
75. CN XII: (Hypoglossal): stick out tongue; move from side to side ( ) Correct Technique ( ) Incorrect Technique ( ) Not 76. Palpates lymph nodes [ ] Under chin/jaw (under chin), (under angle of jaw) tonsillar] [ ] & (in of and behind ear) [ ] (base of skull) [ ] anterior OR posterior cervical chain [ ] [ ] [ ] not
77. CN XI: (Spinal Accessory): shoulders against resistance and head turn against resistance ( ) Correct Technique ( ) Incorrect Technique ( ) Not 78. Performs thyroid examination ( ) Correct Technique ( ) Incorrect Technique ( ) Not 79. Palpate posterior lung fields for tactile fremitus (medial to scapulae at top) bilaterally and symmetrically in all locations. ( ) Correct Technique ( ) Incorrect Technique ( ) Not 80. Percusses the posterior lung fields bilaterally, comparing side to side at the same level ( ) Correct Technique ( ) Incorrect Technique ( ) Not 81. Percusses the right middle lobe in the right anterior axillary line ( ) ( ) ( )
Correct Technique Incorrect Technique Not 82. Auscultates posteriorly (in the back) ( ) Correct Technique ( ) Incorrect Technique ( ) Not 83. Auscultates the right middle lobe - ( ) Correct Technique ( ) Incorrect Technique ( ) Not
84. Percusses anteriorly bilaterally (upper chest in front below clavicles) ( ) Correct Technique ( ) Incorrect Technique ( ) Not 85. Auscultates anteriorly bilaterally (upper chest in front) ( ) Correct Technique ( ) Incorrect Technique ( ) Not
90. Examines patient's heart from the patient's right side ( ) Yes ( ) No 91. Exposes anterior chest sufficiently to inspect the anterior chest. ( ) Correct Technique ( ) Incorrect Technique ( ) Not 92. Palpates to the anterior upper left chest for lifts, thrills, pulsations. ( ) Correct Technique ( ) Incorrect Technique ( ) Not
93. Palpates apical impulse at the apex of the heart. ( ) Correct Technique ( ) Incorrect Technique ( ) Not 94. Auscultates heart with the diaphragm in the correct 4 listening areas with patient supine (laying down). ( ) Correct Technique ( ) Incorrect Technique ( ) Not
95. Auscultates heart with bell in the tricuspid and mitral area ( ) Correct Technique ( ) Incorrect Technique ( ) Not 96. Turn the patient to the left lateral decubitus and listen to apex with the bell (for mitral stenosis) ( ) Correct Technique ( ) Incorrect Technique ( ) Not 97. ( ) ( ) ( )
Have the patient sit up, lean forward, and exhale fully, then listen with the diaphragm at the aortic and pulmonic areas for a murmur of aortic insufficiency. Correct Technique Incorrect Technique Not 98. Palpates peripheral pulses bilaterally. [ ] radial (wrist) [ ] posterior tibial (behind the inner ankle bone) OR dorsalis pedis (top of foot) [ ] not 99. Checks for edema bilaterally by pressing on the patient's shin or ankle. ( ) Correct Technique ( ) Incorrect Technique ( ) Not 100. Examines the abdomen standing at the patient's right side. ( ) Yes ( ) No 101. Exposes the abdomen adequately for inspection ( ) Correct Technique ( ) Incorrect Technique ( ) Not 102. Auscultates the abdomen (for bowel sounds and bruits) ( ) Correct Technique ( ) Incorrect Technique ( ) Not
103. Percusses all 4 quadrants of the abdomen while looking at the patient's face. ( ) Correct Technique ( ) Incorrect Technique ( ) Not 104. Palpates the abdomen ( ) Correct Technique ( ) Incorrect Technique ( ) Not 105. Percusses the liver ( ) Correct Technique ( ) Incorrect Technique ( ) Not
109. Palpates inguinal nodes bilaterally ( ) Correct Technique ( ) Incorrect Technique ( ) Not 110. Did the student palpate all joint areas (for swelling, redness or warmth) by identifying joint spaces and comparing side to side. Cannot be done through sheet or gown. Greater trochanter can be palpated through underwear. [ ] (hands & fingers) [ ] wrists [ ] elbows [ ] [ ] hips (greater trochantor) [ ] [ ] ankles [ ] of the
111. Checks muscle tone by holding arm below elbow and shaking patients relaxed arm with examiner's hand moving up and down. ( ) Correct Technique ( ) Incorrect Technique ( ) Not 112. Did the learner assess against [ ] [ ] Wrist & [ ] Elbow biceps & triceps [ ] Shoulder abductors & adductors [ ] Hip flexors & extensors [ ] Hip & [ ] Knee flexors & extensors [ ] Ankle (stand on heels) [ ] Ankle plantar flexors (stand on toes) [ ] of the 113. Sensation: Sharp/dull arms & legs. ( ) Correct Technique ( ) Incorrect Technique ( ) Not
116. Checks reflexes bilaterally [ ] Biceps [ ] [ ] [ ] Patellar (knee jerk) [ ] Achilles (ankle jerk) [ ] of the 117. Cerebellar function: (dysmetria and ataxia): finger to nose AND heel to shin ( ) Correct Technique ( ) Incorrect Technique ( ) Not
118. Gait: regular gait, toe walking, heel walking, tandem gait ( ) Correct Technique ( ) Incorrect Technique ( ) Not 119. Romberg (Patient stands with eyes closed). ( ) Correct Technique ( ) Incorrect Technique ( ) Not
Concerning Student Performance (CSP) 120. 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 121. Comments: Bottom of Form