UMASS Memorial Medical Center Psychiatry Residency Observed Clinical Interview
Resident Name: Rotation:
DOCTOR-PATIENT RELATIONSHIP Rapport/Alliance Introduces self to patient Puts patient at ease Asks if patient understand/explains purpose of interview Responds appropriately to patient's feelings Eliciting data Moves from open-ended to specific Follows patient's leads/cues to explore important issues and feelings Makes interview a positive experience for patient DOCTOR-PATIENT RELATIONSHIP OVERALL COMPETENCY
Adequately Elicited Yes No Adequately Documented Yes No Adequately Performed Yes No
Comments/Documenting Statement
Comments
CONDUCT OF THE INTERVIEW Presenting symptoms Past psychiatric history Treatment history (hospitalization,medication,psychotherapy, somatic therapies) Family psychiatric history Substance abuse history Legal history Risk (suicide/homicide) Mental Status Examination Appearance Behavior/Demeanor Attention/Comcentration Affect/Mood Speech Thought content Thought processes Cognitive (intellectual, counting/calculating, abstract thinking, judgement/insight) Past Medical & Surgical History CONDUCT OF THE INTERVIEW OVERALL COMPETENCY
Adequately Performed Yes No
Comments
CASE PRESENTATION Presents data in organized manner Interprets data meaningfully CASE PRESENTATION OVERALL COMPETENCY DIFFERENTIAL DIAGNOSIS & FORMULATION Differential Diagnosis Moves from general to specific Considers most likely diagnostic categories Considers using ancillary procedures for appropriate reasons (lab. tests, other procedures) Justifies and/or rules out diagnoses with available data Reaches reasonable provisional diagnosis Formulation Comments appropriately on biological, developmental, psychological, sociocultural factors DIFFERENTIAL DIAGNOSIS & FORMULATION OVERALL COMPETENCY TREATMENT & DISPOSITION
SUMMARY IMPRESSION:
_______________ ADEQUATE INTERVIEW AND DISCUSSION _______________ INADEQUATE INTERVIEW AND DISCUSSION ATTENDING NAME/BEEPER: DATE: ATTENDING SIGNATURE: RESIDENT SIGNATURE