APPENDIX C
EXAMPLES OF FOCUSED ASSESSMENT TOOLS
UCSF Ob/Gyn Surgical Skill Checklist
Surgical Competency
Ob/Gyn - UCSF
Evaluator:
Date:
Resident:
PGY:
1
2
3
Surgical Skills Assessment
4
Rotation:
Rating
Key:
Diagnosis:
Procedure:
(R3) Total Abdominal Hysterectomy
Knew patent history / surgical indication
Operative Checklist
Rating
Key:
0 = poorly or never
1 = sometimes or marginal
2 = usually or average
Necessary lines in place (intravenous, foley)
X = not seen or indicated
1 = performed but poorly
0 = not performed but indicated
2 = performed correctly
Patient positioned correctly on table
Proper stirrups/retractor used for exposure
Lights positioned
1. Discuss the indications for hysterectomy
X
0
1
2
Observed sterile technique
2. Discuss the indications for oophorectomy in conjunction with
abdominal hysterectomy
3. Discuss the post-operative management of a patient status
post TAH
4. Choice of abdominal incision
X
0
1
2
Knew names of instruments
X
0
1
2
Knowledge of anatomy
X
0
1
2
Instrument handling
5. Ligation of round ligament
X
0
1
2
Respected tissue
6. Anterior & posterior leaf of broad ligament opened
X
0
1
2
Moves not wasted
7. Creation of broad ligament window
X
0
1
2
Kept flow of operation / thought ahead
8. Identification of the ureter
X
0
1
2
Used assistants well
9. Ligation of uteroovarian ligament vs infundibulopelvic ligament
(+/-BSO)
10. Double ligation of pedicles
X
0
1
2
Worked well with personnel
X
0
1
2
Worked well as primary surgeon
11. Sharp dissection of bladder flap
X
0
1
2
12. Skeletonize uterine vessels
X
0
1
2
13. Cardinal ligament ligation
X
0
1
2
14. Uterosacral ligament ligation
X
0
1
2
15. Vaginal cuff closure
X
0
1
2
16. Vaginal cuff suspension
X
0
1
2
17. Evaluation for hemostasis
X
0
1
2
TOTAL =
STRENGTHS:
AREAS FOR IMPROVEMENT:
Modified from:
AJOS 1997; 173:226-230
For administrative use
AJOS 1994; 167:423-427
Entered by: _________
Attending Signature:
Date: ______________
Resident Signature:
1
3 = majority or well
4 = always or excellent
EMERGENCY MEDICINE RESIDENCY PROGRAM
RESUSCITATION COMPETENCY FORM
Resident: ____________________________
Date:___________________________
Attending Physician: ____________________________
Location: ________________________
According to the ACGME, a major resuscitation is patient care for which prolonged physician attention is needed and interventions such
as defibrillation, cardiac pacing, treatment of shock, intravenous use of drugs (e.g., thrombolytics, vasopressors, neuromuscular
blocking agents), or invasive procedures (e.g., cut downs, central line insertion, tube thoracostomy, endotracheal intubations) that are
necessary for stabilization and treatment.
I. CLINICAL (Patient Care/Medical Knowledge)
Comments:
Primary Survey:
Airway assessed initially
Breathing then assessed
Oxygen started for respiratory distress
Circulation assessed
Initial interventions
Protocol or treatment guideline
followed
Patient reassessed frequently
Secondary Survey (head to toe
exam):
Procedures performed competently
Y
Y
N
N
NA
NA
Y
N
NA
Y
Y
N
N
NA
NA
Y
N
NA
Y
N
NA
Y
N
NA
Y
N
NA
II. ORGANIZATION (Communication/Professionalism/Systems-Based Practice)
Comments:
Assigned roles
Y N NA
Communicates effectively
Y N NA
Asked for help when needed
Y N NA
Maintains situational awareness
Y N NA
Appropriate handoff (SBAR)
Y N NA
□
COMPETENT
□
2
NEEDS IMPROVEMENT
EMERGENCY MEDICINE RESIDENCY PROGRAM
AIRWAY MANAGEMENT COMPETENCY FORM
Resident: ____________________________
Date:___________________________
Attending Physician: ____________________________
Location: ________________________
I. PREPARATION:
Comments:
Personally assembled and tested all necessary equipment (e.g.,
blades, ET tubes, oral/nasal airways, suction, BVM, etc.)
Properly positioned himself/herself at the head of the bed and all
necessary equipment within arm’s reach
Verbalized an appropriate “Plan B” should initial attempts at airway
management fail (e.g., use of a different type blade, gum elastic
bougie, cric., etc.)
Y
N
Y
N
Y
N
NA
II. MEDICATION MANAGEMENT:
Comments:
Ordered an appropriate induction and paralytic drug,
demonstrating understanding of the particular
indications/contraindications for this drug
Ordered appropriate post-intubation sedation medication,
demonstrating understanding of the particular
indications/contraindications for this drug
Y
N
NA
Y
N
NA
NA
NA
NA
III. AIRWAY TECHNIQUE:
Comments:
Properly positioned patient/head
Effectively performed bag-mask-valve ventilation
Maintained a patent airway (with good positioning, oral/nasal
trumpets, etc.) prior to intubation
Properly applied cricoid pressure
Demonstrated proper use of a laryngoscope and proper ET tube
placement
Confirmed proper tube placement with:
- Auscultation
- End-tidal CO2
- CXR
Y
Y
Y
N
N
N
Y
Y
N
N
Y
Y
Y
N
N
N
NA
NA
NA
Applied necessary alternate rescue airway technique(s)
Y
N
NA
Y
N
NA
Y
Y
N
N
IV. VENTILATOR MANAGEMENT:
Comments:
Ordered appropriate initial ventilator settings
V. DOCUMENTATION:
Comments:
Medications ordered on order sheet
Procedure documented in chart
□
COMPETENT
□
NEEDS IMPROVEMENT
3
Structured Clinical Observation: Resident Interview
LPH&C Medication Management Clinic
John Q. Young, MD, MPP, UCSF Department of Psychiatry, v. 2.5.08
May be used or adapted outside UCSF only with permission of the author jqyoung@lppi.ucsf.edu
Resident Name:_________________________ Attending Name:___________________________
Date:
Instructions: 1. Each resident observed Q4 weeks. 2. Attending checks one box for each row and writes comments at
bottom. 3. Attending reviews with resident and then places in John Young’s box in LP-281 who will give copy to
resident.
Pharmacotherapy Task
0
1
2
3
4
NA
Not
Done with
Done well
Done
Done
suggestions
(meets
extraordinarily
for
expectatio
well – inspires
improvement
ns)
me to do the
same!
Reviews chart
Greets patient with respect & warmth
Begins on time
Maintains frame
Establishes rapport
Initial open ended question
Obtains interval history with focus on target
symptoms, medical or medication changes,
intercurrent psychosocial stressors, progress in
therapy.
Assesses treatment response
Encourages ventilation of feelings related to illness.
Inquires about other treatments/treaters
Assesses substance use/abuse
Assesses adherence, including number of doses
missed in past week and barriers.
Monitors for adverse effects (Sg/Sx, Labs, AIMS, Wt.,
BP), specifically for those associated with prescribed
medications.
MSE appropriately focused
Assesses risk for violence to self and others
If response less than expected, systematic approach to
DDx
Updates treatment plan based on diagnosis, phase of
illness, efficacy and response, adverse effects, & risk
assessment
Modifies treatment plan for less than expected
responders
Develops plan to address adherence if needed
Develops plan to manage adverse effects, if applicable
4
Educates patient about diagnosis, prognosis,
treatment, and/or adverse effects
Provides patient with simple advice on what can do
to help self (e.g., exercise, sleep hygiene).
Solicits and addresses patient’s questions
Conveys hope and optimism and provides
reassurance
Appropriate follow up, incl. labs/tests, consults, next visit
Documentation sufficient
Informs other tx team members of plan, esp. therapists.
5
Structured Clinical Observation: Resident Interview
LPH&C Medication Management Clinic
John Q. Young, MD, MPP, UCSF Department of Psychiatry, v. 8.1.07
May be used or adapted outside UCSF only with permission of the author jqyoung@lppi.usf.edu
Key feedback points, including what done well and at least one task to work on:
DDx for less than Expected
Response







Modify treatment plan for less
than Expected Response
Incorrect primary diagnosis?
Correct primary diagnosis, but insufficient treatment?
Poor adherence?
Under- or un-treated comorbidity (e.g., substance abuse, axis I, axis II
etc…)?
Intervening stressor
Adverse effects of treatment?
Alliance ruptured?
A. Pharmacologic Interventions
 Address adherence
 Reassess dose and duration
 Consider a switch to an alternative treatment
 Augment with evidence based second and third line
pharmacologic treatments
 Treat comorbidities
B. Nonpharmacologic Interventions
 Provide further education
 Provide opportunity to “ventilate” with active listening
 Provide reassurance
 Provide specific psychotherapy
 Refer for psychotherapy
 Behavioral intervention (e.g., sleep hygiene)
 Improve alliance
 Improve treatment of comorbidities such as substance abuse
 Involve family members
6
UC Davis Ob/Gyn Informed Consent Checklist
Communication competencyUCD OBG
Evaluator:
Resident:
Date:
PGY:
1
2
3
4
Communication Skills List
0 = poorly or never
3 = majority or well
1 = sometimes or marginal
4 = always or excellent
Rating Key:
2 = usually or average
Rotation:
Diagnosis:
Procedure: INFORMED CONSENT
Communicates clearly
Communication check list
Rating
Key:
Listens willingly and attentively
X = not seen or indicated
1 = performed but poorly
0 = not performed but indicated
2 = performed correctly
Answers questions and provides explanations
Respects patient does not demean
Uses respectful language
1.Know proper indications for procedure
X
0
1
2
2.Know alternatives
X
0
1
2
Attentive to details of patient comfort
3. Establishes rapport with patient
X
0
1
2
Worked well with personnel
4. Properly describes procedure in understandable terms
X
0
1
2
Nonverbal: shows interest
5. Realistically explains risks of procedure
X
0
1
2
6.Discusses benefits of procedure
X
0
1
2
7. Discusses alternatives to procedure
X
0
1
2
8. Checks for patient understanding often
X
0
1
2
9. Explains preop procedure
X
0
1
2
10.Explains hospital procedure
11. Explains follow up
X
0
1
2
X
X
X
X
X
0
0
0
0
0
1
1
1
1
1
2
2
2
2
2
12. Assess patient questions
Compassion and kind to patient and family
TOTAL =
STRENGTHS:
AREAS FOR IMPROVEMENT:
Attending Signature:
Resident Signature:
7
UNIVERSITY OF NORTH CAROLINA
GRIEVING COMPETENCY INSTRUMENT
Long Form
Directions: Please indicate whether the physician completed the stated actions, with
Y = completed (Yes)
or
N = did not complete (No)
The Physician…
G—Gather
1. Ensured that all important survivors were present prior to delivery of the death notification.
R—Resources
2. Inquired about supportive resources.
3. Facilitated access to supportive resources.
I—Identify
4. Clearly stated the name of the patient.
5. Clearly introduced herself/himself.
6. Clearly stated his/her role in the care of the patient.
Check for Understanding
7. Determined the level of knowledge the survivors possessed prior to their arrival in the
waiting room.
8. Provided an appropriate opening statement (i.e., avoided bluntly stating death of patient).
9. Used preparatory phrases to forecast the news of death.
E—Educate
10. Clearly indicated the chronology of events leading up to the death of the patient.
11. Clearly indicated the cause of death in an understandable manner.
12. Used language appropriate for the survivor’s culture and educational level.
13. Provided a summary of important information to ensure understanding.
V—Verify
14. Used the phrase “dead” or “died.”
15. Avoided using euphemisms.
16. Avoided medical terminology/jargon or clearly explained such terms when used.
Space
17. Was attentive and not rushed in his/her interaction with survivor.
18. Paused to allow the family to assimilate the information before discussing details.
8
I—Inquire
19. Allowed the survivor to react to the information and ask questions or express concerns.
20. Encouraged the survivor to summarize important information to check for understanding.
21. Immediately but appropriately corrected any misconceptions of the survivor.
N—“ Nuts and bolts”
Explained and addressed the following details of the patient's post-mortem care adequately.
22a. Organ donation
22b. Need for an autopsy
22c. Funeral arrangements
22d. Personal effects
G—Give
25. Established personal availability to answer questions for the survivor at a later date.
26. Provided the survivor appropriate information to contact the physician at a later time.
27. Provided the survivor appropriate information to contact resuscitation or post-mortem
care providers.
9