Alaska Community Health Aide Program

Clinical Evaluation Form

CHA/P: / Village: / Date:
Pt. Age: / Gender: / Observer:

Instructions:Next to each item you observe the CHA/P do use the Rate column and place a:
A = PerformsSkill Competently and Appropriate to Level of Training.

I = Needs Improvement, use Comments line to write specifics to improve the Skill

Ø = Skill you do not directly observe the CHA/P do
N/A= Not Applicable if the Skill is not applicable to this patient encounter

Instructor: Review form with CHA/P before Patient encounter. Attach PEF and PEF Review Form to this form.

Chief Complaint/History:

Skill / Rate / Comments: For Needs Improvement - write specifics to improve skill
Ask Patient for Name and DOB (2 identifiers)
Chief Complaint – Write out:
CHA/P observed taking history
Start at the inside front cover and/or appropriate section of CHAM
Pain Assessment
Asks the inside front cover HPI
Asks about illness/chronic health problems
Asks about Medicines
Asks about Allergies
Habit History
TB and Immunizations
LMP/Female questions
Identifies presence or absence of High Risk Health Conditions
Locate the problem specific history
Asks History of Present Illness questions
Asks Past Health History questions
Asks Other History questions
Follows up on positive answers
Regional Additions:

Exam:Observed CHA/P doing the Physical Exam

Skill / Rate / Comments: For Needs Improvement - write specifics to improve skill
General Appearance / [see PEF Review]
Washed hands before and after Exam
Takes appropriate Vital Signs
Temp: Accurate
Pulse: +/- 4 beats
Respirations: +/- 2 breaths
B/P: +/- 4 points
SPO2
Weight
Height/Length
Head Circumference
Performs appropriate Exam using CHAM
Uses correct Exam techniques
Observer agrees with CHA/P Exam findings
Lab Tests appropriate, performed correctly
CHA/P recognizes abnormal findings
Disinfects equipment after Patient
Additional Comments:

Assessment and Plan:

Skill / Rate / Comments: For Needs Improvement - write specifics to improve skill
CHAM Assessment(s) appropriate
Matches history & exam findings
Gives Patient Ed. from CHAM
Determines medicine & dosage
GivesPatient Ed. from Medicine Handbook
Provide Other Care per CHAM
Provides Recheck information
Uses Standing Orders as appropriate
Additional Comments:

Reporting:

Skill / Rate / Comments: For Needs Improvement - write specifics to improve skill
States patient’s name, gender and age
Reports Assessment
Reports History with pertinent +/- findings
Past Health History
Medicines
Allergies and reaction
Asks for provider questions after Hx
States General Appearance
Gives Vital Signs
Gives clear description of Exam findings
Plan for each Assessment
States Patient Ed. given
Asks for provider questions
Confirms Assessment(s) and Plan(s)
Verbal Order/Read Back (VO/RB) *
* CHA/P reads back their written order to provider.
Additional Comments:

Professionalism:

Skill / Rate / Comments: For Needs Improvement - write specifics to improve skill
Meets employer dress code
Prepared, organized, efficient throughout encounter
Establishes/maintains Pt rapport & interaction
Able to self-assess clinical performance*
Collaborates with instructor to learn from identified needs
* CHA/P identifies strengths/areas to improve: How did the patient encounter go? Did I give good pt care? What would I do differently?
What did I learn from this experience? Instructor then evaluates/reviews patient encounter.
Additional Comments:

Approved by ARC/CHAP Directors 5/08