Standardized Patient Checklist

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Checklist

David/Dana Singer 47 y.o.
 


 

Your Name ______________________ Resident Name _____________________

 

GLOBAL RATING

  1. David/Dana Singer 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 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 across the middle and on both sides.”)

YES        NO        UNSURE

  1. The resident asked me to describe the “quality” of the pain. “What does it feel like?” (“Dull, achy, and gnawing most of the time – but when it gets bad it feels sharp, too.”)

YES        NO        UNSURE

  1. The resident asked me to describe the “severity” of the pain on a scale of 1-10. (“Right now it’s about an 8, butlast week it was definitely a 10.”)

YES        NO        UNSURE

  1. The resident asked me to describe the “radiation” of the pain. Does it go anywhere? (“It sometimes shoots down both of my legs, front and back.”)

YES        NO        UNSURE

  1. The resident asked me to how long I have had the pain. (“About a year.”)

YES        NO        UNSURE

  1. The resident asked me to how long the pain lasts. (“My back hurts all the time.”)

YES        NO        UNSURE

  1. The resident asked me if anything makes the pain better or worse. (“Nothing makes it better, except the Percocet, which worked pretty well. Last week, when I missed work, it hurt no matter what I did – sit, stand, anything.”)

YES        NO        UNSURE

  1. The resident asked me if I had urinated (peed) or defecated (stooled) on myself by accident, had numbness in my genitals, or had noticed leg weakness. (“My legs definitely feel weak sometimes – I’ve even fallen acouple times because both of them will just give out on me all of a sudden.”)

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


PHYSICIAN RECOMMENDATIONS

  1. The resident made recommendations for managing my back pain.

DONE        NOT DONE

  1. The resident changed their recommendations when I told them only Percocet would help.

DONE        NOT DONE

  1. The resident explained why they wouldn’t give me Percocet.

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