Cori Stebbins

Geisel On Doc Year 2 SP Interviewing Feedback Template 2015

Used for the Year Two Standardized Patient interviewing sessions.

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Information

Student Name
Conducted on

Evaluation Form

INSTRUCTIONS:
Evaluate the student at their CURRENT LEVEL OF TRAINING as a year two student.

OPEN THE DISCUSSION

Introduction
Agenda Setting

BUILD A RELATIONSHIP

Listening
Empathy & Attitude
Understand patient's perspective
Nonverbal Behavior

GATHER INFORMATION

History
Pace
Organization & Transitions

CONTENT OF HPI

OLDCARTS of CC
Associated Symptoms
PMHx relevant to CC
Fam Hx relevant to CC
Social & Habits Hx
Allergies & Medications including Self-Medications

CLOSE THE INTERVIEW

Share Information
Transition to Preceptor's Entrance Summary

GLOBAL ASSESSMENT

Overall Assessment of Interview
Additional Comments:

Cori Stebbins

Geisel On Doc Year 2 SP Interviewing Feedback Template 2015

Used for the Year Two Standardized Patient interviewing sessions.

Use this Template

Print as PDF

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