UCI Internal Medicine Residency Program
Discharge CEX UCI Team C
Resident Name:
Date:
Activity: The Discharge Process
Competencies Evaluated:
1. Patient Care
2. Communications & Interpersonal Skills
3. Systems-based Practice
Milestones: Must be completed before the end of the PGY-1 year during the Team C block.
This discharge skills clinical evaluation exercise assesses competency in the discharge process.
Each PGY-1 categorical resident must complete this exercise twice during the SWaT Team UCI
block. Before completing the assessment, the senior ward resident will present a critical review
of the articles 1) Promoting effective transitions of care at hospital discharge: a review of key
issues for hospitalists and 2) Transition of Care Consensus Policy Statement provided in the
SWaT Team orientation packet. These articles should be reviewed in the first few days of the
rotation, after which the SWaT Team attending will conduct one Discharge CEX in each of the
two-week sessions of this block.
To complete this exercise, you will need:
 Discharge Summary and Instructions Sheet for a current, real-time discharge that you
have prepared
 A working knowledge of the patient’s hospitalization and their medications
 The opportunity to be present at the bedside with the patient, resident, and attending
Instructions to Evaluator:
1. Clarify your expectations prior to conducting Discharge CEX
2. Review the patient’s written Discharge Summary with the learner in detail using section
one of the Discharge CEX Evaluation Form.
3. Accompany the intern learner to the bedside and observe the intern speaking with and
educating the patient.
4. Provide performance feedback in three areas (no need to go over everything):
Some things they do well, some things to improve.
5. Hand the completed evaluation form to the intern so that he or she can turn it in with the
final packet at the end of the block.
UCI Internal Medicine Residency Program
Discharge CEX UCI Team C
Evaluation
Check if
Completed
Tips for Improvement
Check if
Completed
Tips for Improvement
Discharge Summary Review
Follow-up recommendations to next provider
completed with the appropriate amount of
information
Pending test results included with the appropriate
amount of information
Follow-up appointments clearly stated with
sufficient details
The patient is told whom to call in the event of
problems after discharge
Clear, comprehensive discharge instructions for
medications and other therapies
Clear, comprehensive description of new
medications and potential side effects
Clear review of which medications have been
stopped, started and changed, including OTC meds
and herbals
Medication Reconciliation
Discharge medications reviewed
Medication reconciliation accurate and complete
as noted in the discharge document
Bedside Interview & Patient Education Process
Health Literacy assessment completed including
REALM-SF, knowledge of educational level and
reading level
Education level: Advanced, moderate, limited,
unknown
Reading level: Advanced, moderate, illiterate,
unknown or wrong
Rate the degree of comfort the patient has in
asking clarifying questions 0-5, 5 being most
comfortable. Comment on one behavior
commendable and suggest ways to increase
patients being at ease
Was the bedside RN invited and involved?
Were family members invited if appropriate?
Did the resident use language that was appropriate
to the patient? Identify two phrases that were said
well and two that could be better adjusted to the
Tips for Improvement
UCI Internal Medicine Residency Program
Discharge CEX UCI Team C
patient’s health literacy
Utilized the Teach-back Method to verify
understanding
PCP or other primary physician contacted and sent
the discharge summary
Made clear whom to contact in an emergency or
with questions
Reviewed potential symptoms, side effects or
things to look out for
Recommended things to monitor
Reviewed potential adverse effects or side effects
of medications
Reviewed how to prepare for the follow-up visits
Laboratory work?
Pending tests?
Comments: [
] This exercise was reviewed with the resident.
_______________________________________
Faculty Member Printed Name & Signature
___________________________________
Resident Signature