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Structured Clinical Observation Form

This document is a structured clinical observation form for pediatric residents. It contains sections to evaluate residents on gathering patient data, physical examination skills, and providing information to patients. The form includes checkboxes to indicate which parts of the patient visit were observed and ratings of residents' skills in areas like communication, empathy, medical history taking, and physical exam technique. Feedback points are included for supervisors to note strengths and areas for improvement.

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342 views2 pages

Structured Clinical Observation Form

This document is a structured clinical observation form for pediatric residents. It contains sections to evaluate residents on gathering patient data, physical examination skills, and providing information to patients. The form includes checkboxes to indicate which parts of the patient visit were observed and ratings of residents' skills in areas like communication, empathy, medical history taking, and physical exam technique. Feedback points are included for supervisors to note strengths and areas for improvement.

Uploaded by

api-245673459
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Department Of Pediatrics Pediatric Residency Program

PCC Structured Clinical Observation (SCO)


Trainee: ________________________________
Observer: ______________________________
Patient age:
Patient Gender:

Newborn (1-30 days)


M

PGY1

PGY2

PGY3

Date: _____________________

Infant (30 days - 11 months)

___Years old

Patient type:

new pt.

Established pt.

Type of Visit:

well child

sick visit

follow-up

Indicate the portion of visit and particular items observed. Please check all that apply.

Data gathering

Physical Exam

Interim history (well child)


CC/HPI
Diet/Sleep/Elimination
PMH/Health Maintenance
ROS/HEADS
Development/School History
Family History
Vaccination
Nutrition, Feeding, Weaning
Social/Cultural History

HEENT
Cardiac
Pulmonary
Abdominal
Genitourinary
Orthopedic
Neurological
Growth & Development
Other ________

Information Giving
Anticipatory Guidance
Immunization info
Illness explanation
Management
Follow-up instructions
Other ___________

Specific observations or comments (with reference to Skill Guidelines on other side):


Key Feedback Points:
1.
2.
3.

Time Spent in Observation: ____ min.

Time Spent in Feedback: ____ min.

Resident Signature: ___________________

Preceptor Signature: ___________________

Adapted from L Lane, MD and R Gottlieb, MD, Jefferson Medical College By E Hamburger, MD, S Cuzzi, MD and D Coddington, MD,
Childrens National Hospital, Washington DC

Department Of Pediatrics Pediatric Residency Program

Please place a check by each item below to indicate behaviors that were observed
(Y= yes
N = No NA= no opportunity to observe or not applicable this encounter)
Y

NA

NA

NA

NA

Data gathering
Allows patient/parent to complete opening statement
Starts with open ended questions
Avoids leading questions
Avoids questions with multiple parts
Explicitly elicits patients/parents beliefs about causes of the illness or problem
Asks about remedies or therapies used to address chief complaint
Asks about non-traditional remedies and therapies
Asks specific questions about cultural, religious, spiritual, or ethical values
Asks about life events & circumstances that might affect the patients health/ treatment
Asks about family members or significant others who live in the home or care for the child
Asks for clarification if necessary
Explicitly elicits patients/parents expectations regarding the visit
Proceeds with logical sequencing of questions
Able to take problem based focused history
Cover all important elements of pediatric history (Vaccines, Development, Nutrition, Safety ;etc.)
Interpersonal Skills
Introduces self
Addresses parent / patient by name after initial introductions
Appropriately includes child in interview
Avoids interrupting parent/ patient
Actively listens using nonverbal techniques (e.g. eye contact, nodding)
Expresses empathy (e.g. using tone of voice, That must be hard for you)
Explicitly recognizes patients/parents feelings or concerns (e.g. you seem upset, sad, angry)
Deals effectively with language barriers
Demonstrates sensitivity to health beliefs and religious or spiritual issues
Physical Exam
Washes hands
Matches sequence of exam to cooperation level
Includes all appropriate elements of exam
Leaves out irrelevant elements
Demonstrates correct technique for all portions of the observed exam
Information Giving
Explains confidentiality to adolescent and/or their parent
Avoids jargon and/or explains medical terms if used
Explains diagnosis
Explains management plan
Explains need for follow-up
Uses visual reinforcement (e.g. pictures, models, demonstrations)
Uses written reinforcement (e.g. written instructions, handouts)
Explicitly asks for patient/parent input in management plan
Adapts plan as needed to suit individual circumstances, cultural or health beliefs
Asks patient / parent for their understanding of treatment plan
Solicits questions
Asks about patient/parents ability to follow treatment plan
Explains when, why, how family should contact physician
Provides summary of discussion

Adapted from L Lane, MD and R Gottlieb, MD, Jefferson Medical College By E Hamburger, MD, S Cuzzi, MD and D Coddington, MD,
Childrens National Hospital, Washington DC

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