Jenny Jones V2017 (H&P & Weight Loss)

Jenny Jones v2017 (H&P & weight loss)

SP

SP SPA 1 (History) (SPA 1)

1.
Item 4: Eliciting the Narrative Thread
Notes: / 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.
/ ()
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
Notes: / 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.
/ ()
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 Skills--Types of Questions (edited)
Notes: / 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.
/ ()
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
The Learner used a few leading, why, or multiple questions. / ()
2 / ()
1. The Learner asked many why questions, multiple questions, or leading questions.
4.
Item 21: Closure
Notes: / 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).
/ ()
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.
Learner describes physical exam or procedures to you
Notes: / Learner should tell patient that he/she is going to do a physical exam. Should explain in general terms each body system exam (i.e. I'm going to examine your heart now, I'm going to examine your abdomen now, etc.).
/ ()
Yes / ()
No
8.
Examines you appropriately (not through gown or clothing). / ()
Yes / ()
No
9.
Comments:

SP SPA 7 (Communication) (SPA 7)

10.
Item 1: Opening
Notes: / 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.
/ ()
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
Notes: / 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.
/ ()
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.
12.
Item 13: Verbal Facilitation Skills
Notes: / The Learner used facilitation skills throughout the interview. Verbal encouragement, use of short statements and echoing were used when appropriate.
/ ()
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.
13.
Item 14: Non-Verbal Facilitation Skills
Notes: / 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.
/ ()
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 on the interview. Eye contact was not attempted or was uncomfortable.
14.
Comments:

SPA 17

15.
Drapes appropriately and protects modesty.
Notes: / Learner should lower gown from above to examine upper chest while keeping the breasts covered. The learner should raise the gown from below, keeping the breasts covered to examine the lower chest. For the abdominal exam the learner raises gown and lowers sheet to expose all of abdomen down to top of symphysis pubis. For straight leg raising places sheet between legs before doing straight leg raising.
/ () Yes / () No
16.
Learner considers your comfort during exam
Notes: / Pulls out foot rest when patient is laying down; avoids unnecessary position changes, helps or offers to help patient sit/stand up, is not unnecessarily rough with physical exam.
/ () Yes / () No
17.
Comments:

Student of Concern (SOC)

18.
Do you have concerns about this student's performance that have NOT been represented by any other checklist item?
Notes: / This question is intended to identify students with significant problems THAT WOULD NOT be identified by the checklist grade. These are student who may not be ready to progress and/or who may need remediation.
/ ()
Yes (comments required) / ()
Possibly (comments required) / ()
No, there are no concerns not reflected on the checklists.
19.
Comments:

Faculty Observation and Narrative

FON SPA 1 History (SPA 1)

20.
Establishes or confirms the chief 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.
Notes: / Including onset, constant or intermittent, getting worse since onset, etc. Only 1 question required to score "yes."
/ ()
Yes / ()
No
28.
Precipitant or environment/context in which pain occurs.
Notes: / What was going on when the problem started? What was happening just before it started? How are you faring in your current environment? (Any 1 question is acceptable). There may be overlap between this question and timing and/or aggravating & alleviating symptoms.
/ ()
Yes / ()
No
29.
Severity
Notes: / For pain quantified on a 10 pt. scale. For other symptoms (fatigue, shortness of breath, etc. better quantified by a description of how much it interferes with ADLs (activities of daily living).
/ ()
Yes / ()
No
30.
History of this pain before / ()
Yes / ()
No
31.
Past medical history
Notes: / chronic illnesses, hospitalizations. Any 1 question is sufficient.
/ ()
Yes / ()
No
32.
Past surgical/ob history
Notes: / surgeries, major trauma, fractures . Any one question is sufficient.
/ ()
Yes / ()
No
33.
Prescription Medications / ()
Yes / ()
No
34.
OTC medications
Notes: / vitamins, herbs, etc.
/ ()
Yes / ()
No
35.
Medication allergies / ()
Yes / ()
No
36.
Learner mentions age appropriate screening/immunizations (colonoscopy, flu vaccine, mammogram, pap smear, etc.)
Notes: / Any one mention is sufficient to score "yes."
/ ()
Yes / ()
No
37.
Asks generally about Family History.
Notes: / any disease runs in your family?, etc.
/ ()
Yes / ()
No
38.
Establishes health status of 1st degree relatives or age at and cause of death. Must ask about all 1st degree relatives to score "yes."
Notes: / Is your _____ living? If yes, how old is he/she and does he/she have any health problems? If no, how old was he/she when he/she died and what did he die of?
/ ()
Yes / ()
No
39.
Asks about specific Family History related to current chief complaint.
Notes: / Examples: has anyone in the family had a disease or symptoms like this? Are there any diseases in your family in this body system (would indicate specific system)
/ ()
Yes / ()
No
40.
Living situation.
Notes: / Questions such as "Tell me a little about where you live." Any question is sufficient to score "yes."
/ ()
Yes / ()
No
41.
Relationship status
Notes: / Typical question might be: Are you in a relationship with anyone? May or may not follow up on answer to get more information about the relationship for the purposes of this exam.
/ ()
Yes / ()
No
42.
Smoking history
Notes: / If he/she has ever smoked need to find number of years and packs smoked per day. If prior smoker and has stopped need to find out how many years since he's smoked.
/ ()
Yes / ()
No
43.
Alcohol intake.
Notes: / If yes, need to determine drinks per day (or week or month).
/ ()
Yes / ()
No
44.
Recreational/street drug use.
Notes: / If yes, need to determine drug, quantity and frequency.
/ ()
Yes / ()
No
45.
Sexual history
Notes: / Needs to determine whether engaging in high risk behaviors.
/ ()
Yes / ()
No
46.
Eating habits/diet.
Notes: / Any question about diet or eating habits will suffice.
/ ()
Yes / ()
No
47.
Exercise/activity
Notes: / Any question about exercise or level of activity will suffice.
/ ()
Yes / ()
No
48.
Sources of stress.
Notes: / Any question about whether patient experiences stress or whether there are stressors in his/her life will suffice.
/ ()
Yes / ()
No
49.
Support systems
Notes: / Any question about support of family/friends, a support system, supportive environment, or a question about being close to friends/family will suffice.
/ ()
Yes / ()
No
Scoring for ROS
Student must ask at least 1 question for each system to score "yes."
50.
General symptoms
Notes: / e.g. weight loss, fatigue, fever, chills
/ ()
Yes / ()
No
51.
HEENT
Notes: / e.g. blurry vision, sinus problems, sore throat
/ ()
Yes / ()
No
52.
Endocrine system
Notes: / e.g. polyuria (excessive urine), polydipsia (excessive thirst), polyphagia (excessive appetite), heat/cold intolerance, history of thyroid issues,
/ ()
Yes / ()
No
53.
Pulmonary
Notes: / e.g. hemoptysis (coughing up blood), cough or dyspnea (difficulty breathing)
/ ()
Yes / ()
No
54.
Cardiovascular
Notes: / e.g. chest pain, palpitations, syncope (fainting, passing out)
/ ()
Yes / ()
No
55.
Gastrointestinal
Notes: / e.g. nausea or vomiting, change in bowel habits, diarrhea, black or tarry stools, trouble swallowing, change in appetite or diet
/ ()
Yes / ()
No
56.
GU
Notes: / e.g. dysuria (painful urination), hematuria (blood in urine)
/ ()
Yes / ()
No
57.
Reproductive
Notes: / e.g. for males: erectile dysfunction, difficulty starting urine stream,
/ ()
Yes / ()
No
58.
Musculoskeletal
Notes: / e.g. pain, stiffness, swelling
/ ()
Yes / ()
No
59.
Neurological
Notes: / e.g. dizziness, numbness, weakness
/ ()
Yes / ()
No
60.
Psychiatric
Notes: / e.g. mood, depression,
/ ()
Yes / ()
No
61.
Hematology/Oncology
Notes: / e.g. swollen glands, easy bruising, bleeding
/ ()
Yes / ()
No
62.
Comments:

FON SPA 2 (Physical Exam) (SPA 2)

63.
CN II: (Optic): checks visual fields by confrontation having patient quantify fingers in each of four quadrants between patient and examiner (can do double simultaneous stimulation. Can check peripheral OR central visual fields.
Notes: / 1. Has patient focus on nose or forehead; 2. Keeps hands 2-3 ft away from patient's eyes; 3. Check each central field with finger count (1,2,5) and peripheral fields finger wiggle in each quadrant; 4.Tests each eye independently with patient covering one eye at a time. 5. All instructions must be given to patient and all steps done correctly for full credit.
/ ()
Correct Technique / ()
Incorrect Technique / ()
Not Done
64.
CN III, IV, and VI: (Oculomotor, Trochlear, and Abducens) - Check EOMs using an "H" pattern.
Notes: / The patient must be instructed to follow the examiner's finger or a light without moving the head.
/ ()
Correct Technique / ()
Incorrect Technique / ()
Not Done
65.
CN II & III: (Optic & Oculomotor): direct and consensual pupil exam
Notes: / Must do both for full credit. 1. In direct pupil contraction is noted when a light is shined that that eye. 2. For consensual, pupil contraction is noted when a light is shined in the opposite eye.
/ ()
Correct Technique / ()
Incorrect Technique / ()
Not Done
66.
Performs fundoscopic examination.
Notes: / Must darken the room, hold the instrument correctly, get close enough to the patient, ask the patient to fix his/her gaze on a point. If any of these items are omitted then the exam is not done "correctly." If patient is wearing glasses they must be removed.
/ () Correct Technique / () Incorrect Technique / () Not Done
67.
CN V: (Trigeminal): Tests light touch using cotton swab or finger on all three areas bilaterally.
Notes: / Has patient close eyes and ask when they feel it. OR can leave eyes open and test simultaneously and ask whether the sides feel the same (or different).
/ ()
Correct Technique / ()
Incorrect Technique / ()
Not Done
68.
CN VII: (Facial) Test facial muscle strength: have patient raise eyebrows, smile, and keep eyelids closed against resistance. / ()
Correct Technique / ()
Incorrect Technique / ()
Not Done
69.
CN VIII: (Acoustic): Checks hearing by finger rub. Must test each ear separately. / ()
Correct Technique / ()
Incorrect Technique / ()
Not Done
70.
Performs otoscopic examination.
Notes: / Uses otoscope correctly; retracts ear upward and back using the hand not holding the otoscope.
/ ()
Correct Technique / ()
Incorrect Technique / ()
Not Done
71.
Examines nose by using otoscope to visualize septum, nares, turbinates. / ()
Correct Technique / ()
Incorrect Technique / ()
Not Done
72.
Palpates the frontal and maxillary sinuses. / () Correct Technique / () Incorrect Technique / () Not Done
73.
Examines oropharynx.
Notes: / Looks in the mouth with a light.
/ () Correct Technique / () Incorrect Technique / () Not Done
74.
CN IX & X: (Glossopharyngeal and Vagus): palatal elevation
Notes: / Have the patient say "ah" while looking at palate. The learners are instructed NOT to do gag reflex. Note that this may be combined with looking in the patient's mouth.
/ ()
Correct Technique / ()
Incorrect Technique / ()
Not Done
75.
CN XII: (Hypoglossal): stick out tongue; move from side to side
Notes: / Must do both for full credit.
/ ()
Correct Technique / ()
Incorrect Technique / ()
Not Done
76.
Palpates lymph nodes
Notes: / If "piano" fingers used, learner does not score a check. If done through gown no credit is given.
/ []
Under chin/jaw [submental (under chin), submandibular (under angle of jaw) tonsillar] / []
preauricularpostauricular (in front of and behind ear) / []
occipital (base of skull) / []
anterior OR posterior cervical chain / []
supraclavicular / []
infraclavicular / []
not done
77.
CN XI: (Spinal Accessory): shrug shoulders against resistance and head turn against resistance
Notes: / Can do either for full credit.
/ ()
Correct Technique / ()
Incorrect Technique / ()
Not Done
78.
Performs thyroid examination
Notes: / Examines from behind the patient and asks him/her to swallow, palpates both sides of the neck.
/ ()
Correct Technique / ()
Incorrect Technique / ()
Not Done
79.
Palpate posterior lung fields for tactile fremitus (medial to scapulae at top) bilaterally and symmetrically in all locations. / ()
Correct Technique / ()
Incorrect Technique / ()
Not Done
80.
Percusses the posterior lung fields bilaterally, comparing side to side at the same level / ()
Correct Technique / ()
Incorrect Technique / ()
Not Done
81.
Percusses the right middle lobe in the right anterior axillary line / ()
Correct Technique / ()
Incorrect Technique / ()
Not Done
82.
Auscultates posteriorly (in the back)
Notes: / 3 locations on each side comparing left to right. Patient must be asked to breathe in and out through mouth or take deep breaths. Stethoscope must remain in contact with the skin throughout a full cycle of inspiration & expiration to score "correct."
/ () Correct Technique / () Incorrect Technique / () Not Done
83.
Auscultates the right middle lobe -
Notes: / laterally under right arm pit or under R nipple/breast. Stethoscope must remain in contact with the skin throughout a full cycle of inspiration & expiration to score "correct."
/ () Correct Technique / () Incorrect Technique / () Not Done
84.
Percusses anteriorly bilaterally (upper chest in front below clavicles) / ()
Correct Technique / ()
Incorrect Technique / ()
Not Done
85.
Auscultates anteriorly bilaterally (upper chest in front)
Notes: / Patient must be asked to take deep breaths or breathe in and out through mouth. Needs to listen in at least one place on each side (right/left). Stethoscope must remain in contact with the skin throughout a full cycle of inspiration & expiration to score "correct." May listen above or below clavicle.