Standardized Patient Checklist

Open SP Checklist

Michael (Michelle) Thomas 58 y.o.

 


 
 
Your Name ______________________ Resident Name _____________________


GLOBAL RATING

  1. Michael/Michelle Thomas was satisfied with this resident physician encounter.

YES        NO

COMMENTS:



HISTORY

Please record whether the resident elicited the following information.

If the resident DID elicit the statement, select “YES.”

If the resident DID NOT elicit the statement, select “NO.”

If you are unsure, select “UNSURE.”


Use the following guide to answer:

  1. The resident asked about my general well-being: “How are you doing?”

YES        NO        UNSURE

  1. The resident asked me to tell them about my back pain.

YES        NO        UNSURE

  1. The resident asked me to describe the site or location of the pain. “Where on your back does it hurt?” (“In my lower back, right in the center where my spine is.”)

YES        NO        UNSURE

  1. The resident asked me to describe the “quality” of the pain. “What does it feel like?” (“Deep and achy.)”

YES        NO        UNSURE

  1. The resident asked me to describe the “severity” of the pain on a scale of 1-10. (“About a 5.”)

YES        NO        UNSURE

  1. The resident asked me to describe the “radiation” of the pain. “Does it go anywhere?” (“Actually, yes – it seems to shoot down my right let sometimes, right down the back.”)

YES        NO        UNSURE

  1. The resident asked me how long I have had the pain. (“Around 4 months.”)

YES        NO        UNSURE

  1. The resident asked me how long the pain lasts. (“Well, it started out bothering me for maybe a half an hour at a time, but now it lasts a couple of hours.”)

YES        NO        UNSURE

  1. The resident asked me if anything makes the pain better or worse. (“Bending over definitely does – that’s why I had to drop aerobics. The car trips to Northern Virginia kill me. And sitting at the computer surfing the internet – that gets it going too. Sometimes even little things like coughing or sneezing make it worse.”)

YES        NO        UNSURE

  1. The resident asked me if I had urinated or defecated on myself by accident, had numbness in my genitals, or had noticed leg weakness. (“No, not that I’m aware of.”)

YES        NO        UNSURE


PHYSICAL EXAMINATION

  1. The resident asked me to stand up for part of the exam.

DONE        NOT DONE

  1. The resident looked at my back while I was standing.

DONE        NOT DONE

  1. The resident asked me to bend forwards.

DONE        NOT DONE

  1. The resident asked me to bend backwards.

DONE        NOT DONE

  1. The resident asked me to bend from side to side.

DONE        NOT DONE

  1. The resident asked me to keep my hips and feet still while turning my upper body left and right.

DONE        NOT DONE

  1. The resident touched the bony parts of my lower back.

DONE        NOT DONE

  1. The resident touched the muscles around my lower back and buttocks.

DONE        NOT DONE

  1. The resident touched the skin on my legs and the tops of my feet and asked me if there were any areas of numbness.

DONE        NOT DONE

  1. The resident asked me to sit for part of the exam.

DONE        NOT DONE

  1. The resident pushed down on my knee or thigh while I was sitting, and asked me to push upwards against him/her.

DONE        NOT DONE

  1. While I was sitting, the resident asked me to kick my lower leg out while he/she pushed against it.

DONE        NOT DONE

  1. The resident asked me to point my toes upwards (towards the sky, or my nose).

DONE        NOT DONE

  1. The resident asked me to point my toes downwards (like a ballet dancer on tiptoe).

DONE        NOT DONE

  1. The resident tapped on my knees with a reflex hammer or side of their stethoscope.

DONE        NOT DONE

  1. The resident tapped on the back of my heel with a reflex hammer or the side of their stethoscope.

DONE        NOT DONE

  1. The resident asked me to lie down for part of the exam.

DONE        NOT DONE

  1. The resident asked me to straighten my leg and lift it upwards (either while I was seated or lying down), and asked if I had pain.

DONE        NOT DONE

  1. While lying on my back, the resident asked me to bend one knee and cross my ankle over my other knee, and asked if I had pain.

DONE        NOT DONE

  1. The resident asked me to walk normally.

DONE        NOT DONE

  1. The resident asked me to walk on my heels.

DONE        NOT DONE

  1. The resident asked me to walk on my toes.

DONE        NOT DONE


PATIENT-PHYSICIAN INTERACTION

How was the resident you saw at:

  1. Allowing you to answer questions without interrupting?

POOR        FAIR        GOOD

  1. Behaving warmly, but professionally throughout the entire encounter?

POOR        FAIR        GOOD

  1. Examining you in a way that felt professional and comfortable?

POOR        FAIR        GOOD