CLINICAL OTOLARYNGOLOGY – 068-003 – PATIENT EXPERIENCES CHECKLIST
Completion of the items on this form is required. You will not receive a grade until it is
completed and returned. The completed form is due when you take your final
examination. Failure to complete the minimum required items will result in an
incomplete grade for the course. You must have your resident co-sign the checklist;
uncosigned checklists will result in an incomplete grade for the course..
Guidelines for completion of this checklist:
SECTION A: During your rotation, we would like for you to have some experience with the most
common types of clinical situations that an otolaryngologist would encounter. In a 2 week
rotation, it is difficult to have all of these experiences with an actual patient. There are patientbased clinical scenarios that are available online (COOL cases) that are designed to supplement
and reinforce the clinical experience that you will have on the clerkship rotation. There are
currently 29 COOL cases available. At the minimum, you are required to complete the 12
COOL cases that are listed below in section A1. You may complete the other COOL cases
that are listed in section A2 for your own education if you desire.
As you do encounter patients on the rotation, either in the clinics, in surgery, or on call, you will be
asked to document the level of clinical participation that you had with that patient. Additional
clinical scenarios that you may encounter are listed in section A2. At the minimum, you must
have had some clinical participation with an actual patient for eight of the following patient
scenarios that are listed in either section A1 or A2. You may use the same patient to fulfill
several items.
FULL participation will include complete history and physical exam, diagnosis development, and
thorough clinical reasoning which support management: formulation or review of treatment plan,
appropriate use of diagnostic or monitoring tests, schedule for follow-up, appropriate counseling
and/or patient education, appropriate medication review and prescription.
PARTial participation includes completion of history and physical, but not developing a diagnosis
and treatment plan.
Observe level means observing history and/or physical exam, but not participating in care.
SECTION B: During your rotation, we require that you observe and/or perform the 3 procedures
listed in section B. At the minimum, you must have at least observed in person or seen a
portion of the procedure in a COOL case for all three of the listed procedures.
SECTION C: During your rotation, you must complete the call requirement. At the minimum,
you must complete one evening call from 5 pm to 8am Monday through Friday, OR one
weekend shift from 9am to 9 pm Saturday or Sunday.
SECTION D: During your rotation, you must complete a short, 3-5 minute oral presentation on a
clinical topic of your choice. This presentation will be given to your team at a mutually agreed
upon time. At the minimum, you must complete this oral presentation to your team.
A. PATIENT CARE
1. REQUIRED patient experiences
Epistaxis
Nasal Obstruction
Rhinosinusitis
Allergic Rhinitis
Otitis Media
Sensorineural Hearing Loss
(2008)
Tinnitus
Hoarseness
Adult Neck Mass
Dysphagia
Oral Cavity Lesions
Sleep Medicine for the
General Practitioner
□ FULL
□ FULL
□ FULL
□ FULL
□ FULL
□ FULL
□ PART
□ PART
□ PART
□ PART
□ PART
□ PART
□ OBS
□ OBS
□ OBS
□ OBS
□ OBS
□ OBS
□ COOL
□ COOL
□ COOL
□ COOL
□ COOL
□ COOL
date:_____
□ FULL
□ FULL
□ FULL
□ FULL
□ FULL
□ FULL
□ PART
□ PART
□ PART
□ PART
□ PART
□ PART
□ OBS
□ OBS
□ OBS
□ OBS
□ OBS
□ OBS
□ COOL
□ COOL
□ COOL
□ COOL
□ COOL
□ COOL
date:_____
□ FULL
□ FULL
□ FULL
□ PART
□ PART
□ PART
□ OBS
□ OBS
□ OBS
□ COOL
□ COOL
□ COOL
date:_____
□ FULL
□ FULL
□ PART
□ PART
□ OBS
□ OBS
□ COOL
□ COOL
date:_____
□ FULL
□ FULL
□ FULL
□ PART
□ PART
□ PART
□ OBS
□ OBS
□ OBS
□ COOL
□ COOL
□ COOL
date:_____
□ FULL
□ PART
□ OBS
□ COOL
date:_____
□ FULL
□ FULL
□ FULL
□ FULL
□ FULL
□ FULL
□ PART
□ PART
□ PART
□ PART
□ PART
□ PART
□ OBS
□ OBS
□ OBS
□ OBS
□ OBS
□ OBS
□ COOL
□ COOL
□ COOL
□ COOL
□ COOL
□ COOL
date:_____
□ FULL
□ PART
□ OBS
□ COOL
date:_____
date:_____
date:_____
date:_____
date:_____
date:_____
date:_____
date:_____
date:_____
date:_____
date:_____
2. Additional patient experiences
Cholesteatoma (Otoscopy)
Ear Canal Obstruction
Management of Positional
Vertigo
Otalgia
Sudden Sensorineural
Hearing Loss (2009)
Pediatric Stridor
Pediatric Neck Mass
Non-melanomatous
Cutaneous Malignancies
Hoarseness/Laryngeal
Neoplasms
Salivary Disease
Pharyngitis
Nasal Trauma
Chronic Cough
Reflux
Management of the Thyroid
Nodule
Facial Soft Tissue Trauma
date:_____
date:_____
date:_____
date:_____
date:_____
date:_____
date:_____
date:_____
date:_____
date:_____
B. COMMON PROCEDURES
Flexible Laryngoscopy
Audiogram Evaluation
Ear Microscope Exam
□ FULL
□ FULL
□ FULL
□ PART
□ PART
□ PART
□ OBS
□ OBS
□ OBS
□ COOL
□ COOL
□ COOL
date:_____
date:_____
date:_____
C. ORAL PRESENTATION
Date of presentation: ___________
D. COMPLETION OF CALL
Date of call: ___________
I certify that these checklist items have been completed with honest and integrity.
_____________________________________
STUDENT SIGNATURE
_____________________________________
RESIDENT SIGNATURE