Standardized Patient Checklist

Open SP Checklist

Andrew/Andrea Duncan 72 y.o.
 


 

Your Name ______________________ Resident Name _____________________

 

GLOBAL RATING

  1. Andrew/Andrea Duncan was satisfied with this resident physician encounter.

YES NO

COMMENTS:

 

 

HISTORY

Please record whether the learner elicited the following information.

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

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

If you are unsure, select “UNSURE.”

Use the following guide to answer:

  1. The resident asked me 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 middle where my spine is.”)

YES        NO        UNSURE

  1. The resident asked me to describe the “quality” of the pain. “What does it feel like?” (“My back feels dull and achy –my legs feel prickly, crampy and tired, but only after I walk.”)

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? (“Yes – after I walk for five minutes, I can feel the pain shoot from my buttocks on down to my feet.”)

YES        NO        UNSURE

  1. The resident asked me how long I have had the pain. (“The back pain has been going on for about four months – the leg pain came on in the last month.”)

YES        NO        UNSURE

  1. The resident asked me how long the pain lasts. (“My back hurts almost all the time. My legs get better pretty quickly after I sit down.”)

YES        NO        UNSURE

  1. The resident asked me if anything makes the pain better or worse. (“Bending over, squatting, or curling up in bed seems to make it a little better. Walking definitely makes 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. (“Once in a while I’ll lose some urine if I laugh or sneeze, otherwise, no.”)

YES        NO        UNSURE

PHYSICAL EXAMINATION

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

DONE        NOT DONE

  1. The resident asked me to bend forward while I was standing.

DONE        NOT DONE

  1. The resident asked me to bend backwards while I was standing.

DONE        NOT DONE

  1. The resident asked me to bend from side to side while I was standing.

DONE NOT DONE

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

DONE        NOT DONE

  1. The resident touched the body parts of my lower back (while I was standing or sitting).

DONE        NOT DONE

  1. The resident touched the muscles around my lower back and buttocks (while I was standing or sitting).

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 (while I was standing or sitting).

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 s/he pushed against it.

DONE        NOT DONE

  1. While I was sitting, the resident asked me to point my toes upwards (towards the sky or my nose).

DONE        NOT DONE

  1. While I was sitting, the resident asked me to point my toes downwards (like a ballet dancer on tiptoe).

DONE        NOT DONE

  1. While I was sitting, the resident tapped on my knees with a reflex hammer or side of their stethoscope.

DONE        NOT DONE

  1. While I was sitting, 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