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CLINICAL MEDICINE COMPETENCY BASED ASSESSMENT AN INTRODUCTION TO THE END OF YEAR CUMULATIVE WRITTEN EXAM, OBJECTIVE STRUCTURED CLINICAL EXAMS, AND STANDARDIZED PATIENT EXAMS Information for rising Third and Fourth Year Medical Students This is a guide to end of second year and end of third year testing. The guide is intended to review the essential information students must demonstrate they have acquired during the second and third year in order to make academic progress. The guide provides a description of the comprehensive testing and the methods by which the scores are derived. The guide is meant to prepare students for taking the end of second year and end of third year exams. In addition, the guide may be used as suggested content in preparing for COMLEX PE. CONTENTS An Introduction Clinical Competency Training and Testing 2 General Guidelines 3 Humanistic Domain 4 The Medical History 5 The Physical Examination 7 Formulating a Differential and Diagnostic Tests 8 The Medical Record 9 Content Overview 10 The Standardized Patients 10 Scoring Methods 13 Keys to Success 15 END OF YEAR EXAM 16 OMT During OSCE 16 Introduction to Clinical Competency Testing In Medicine, clinical competency is based on knowledge, communication, critical thinking, and clinical procedural skills. The clinical competency skills each osteopathic medical student should master are contained in this document. These include the osteopathic core competencies and the clinical competencies as defined by the Curriculum Committee and the Assessment Committee of VCOM. The individual clinical skills each student is to master are taught in each block by the faculty. The summary in this document is a review of the clinical skills that will be assessed at the end of year two and three, and the methods by which they are evaluated, including the key elements of the exams. As a competency based exam, you will either pass or fail the exam. You will be given an objective score which is derived from evaluations of performance: yes – (performed correctly) OR no- (performed partially, incorrectly, or not at all.) When standardized patients are used, each will simulate a common patient from a medical outpatient practice, emergency department, or hospital setting. In each case you will be told the setting in which the case takes place. You will be asked to perform a focused history and physical to evaluate a patient, to develop a differential diagnosis, to order/utilize reasonable diagnostic techniques to attain only the required clinical information provided, to narrow the diagnosis, and where appropriate to order treatment. General Guidelines: The clinical skills testing requires the student to perform the same as they would in a professional clinical setting. The student must therefore behave in a professional and ethical manner at all times. This includes not talking in the halls or discussing patient cases between patients. No sharing of patient information to other students or patients – the same rules apply as in the clinical setting and just as in HIPPA guidelines, you must not share this information. In addition, many case scenarios are used in clinical skills testing for each complaint. The different scenarios lead the student physician to different answers as well as different diagnoses. Sharing of information can be harmful to your peers as they reach the wrong diagnosis, rather than following the case before them. Humanistic Domain: In the humanistic domains you will be judged on communication skills and professionalism. These include such skills as: appropriately introducing one’s self, assuring you have the appropriate patient, washing of hands when entering the room, asking permission to touch a patient prior to an exam, explaining an exam prior to and when it is performed, explaining the conditions you are considering when ordering tests assuring the patient is in agreement with the tests you are ordering (patient partnering) explaining your plan to the patient caring for a patient’s direct needs (is the patient comfortable – sitting, lying, etc.; is the patient in pain – have you assessed and addressed the pain,) assuring the patient has a support system ( someone to care for them if the patient is to go home for example) assuring the patient understands the plan (any medication orders, asking if there is a question or concern about your plan) always making good eye contact always watching for non-verbal clues from the patient – (painful expressions, anxiety, depression, confusion, grief/loss etc.) allowing the patient time to answer open ended questions, redirecting them occasionally in a sensitive manner if they ramble attentiveness to your own dress, non-verbal cues, and other patient barriers that may exist. The Medical History: Through efficient information gathering a medical history is performed. In the history gathering, you must be able to demonstrate the ability to efficiently collect patient information unique to the presentation of symptoms from each patient. A relevant medical history is the history relates specifically to the chief complaint of the patient. The relevant medical history includes the location and duration of the complaint, the exacerbating and relieving factors of the chief complaint, and whether the symptoms are increasing or decreasing, or whether the symptoms wax and wane. The relevant history includes the review of the system to which the complaint is related. If pain is present assessing the level of pain on a scale of 1 to 10 should be performed. Gathering a general medical history is important in each patient. This history includes the data relevant for all patients, regardless of their current complaint. This history includes previous serious illnesses, previous hospitalizations, previous surgeries, and any previous trauma. Also relevant in this history is the patient’s current medications, immunization history, and any allergies or medication intolerances. Gathering a social history is also be needed. The most important steps of a social history are the support systems at home, the marital status of the patient, the occupation and previous occupation of the patient. The patient’s risk factors are assessed at this time as well including the smoking history, alcohol history, illicit or prescription drug dependence history, and prior treatment for mental illness. You must also gather a family history for significant familial or genetic diseases. Listen carefully and provide the appropriate response to loss of significant family members, you may need to explore the grief and loss issues if recent of symptoms warrant. The final element of the medical history is the review of systems. If a patient is being seen for a full physical this would include all systems. In the case of second and third year testing, the systems directly related to a chief complaint should be researched. Examples of the relevant systems for complaints are listed below. This is not the entire list, however demonstrates the rationale. Chest pain – cardiac, pulmonary, musculoskeletal, and upper abdomen. Shortness of breath – cardiac, pulmonary, endocrine. Abdominal pain – cardiac, GI, renal, and GU. Dizziness – ENT, Vision, Neuro, Vascular, Cervical-musculoskeletal Confusion – Circulatory, Neuro, Psychiatric Headache – Neuro, Psychiatric, ENT, Vision Nausea – GI, Renal, GU, Cardiac Cough – ENT, Pulmonary Again these are only a few of the 128 ways a patient may present, but this gives you the idea that a number of systems may need to be explored related to any one complaint. The following page is an example of a review of systems for a complete history and physical. Recognize that focusing on a specific chief complaint, additional questions may arise in your review of systems. This is an example. Risk Factors and Review of Systems: Skin: ___Wears sunscreen: ___Acne ___Skin rash ___Previous sunburns __ New moles or growths: __Moles or growths changed in appearance: __skin rash ___pruiritis ____hives or wheels ___edema EYES ___ Headaches, ___Vision loss, ___Blurred vision ____ Double vision, ___Eye pain ____History of blindness or glaucoma in family ____Previous eye exam ENT ____Recurrent Allergies ____Recurrent sinus/throat infections ___ Ear pain ___ Nasal pain ___Throat pain ___Recurrent nosebleeds, ____ Ringing in ears, ___Ear drainage ___Hoarseness or difficulty talking ____ Recurrent toothache ___Mouth pain ___ Facial pain ____ Swelling of lymph nodes ___Mass in neck ___Neck Pain ___last hearing exam ___snoring Respiratory:__Smoking /tobacco __Shortness of breath (at rest or exertion) ___ Short of breath lying flat ___cough ___ Wheezing ___Asthma history ___ Chronic cough ___ Sputum production ____ Blood in Sputum ____History of chronic bronchitis __ History of Emphysema ___Exposure to Asbestos, or toxic substance at work ___ Hx. respiratory cancer __ Recurrent Pneumonia ___Chest pain ___ Rib pain Gastrointestinal: __ Diarrhea __Constipation __Abdominal Pain (location, exacerbation, pain level, relief) ___Ulcer hx. __Heartburn or reflux ____hx (GERD) __Difficulty Swallowing ___ Nausea ___Vomiting ____ Anorexia /appetite loss ___ Hernia ____ Significant Weight Loss ____ Previous AbdominalSurgery ___Blood in Stool __Vomited blood ___ Gall Bladder Dx./stone ___ prior Appendicitis ___Good intolerance _________Date last sigmoid/ colonoscopy __________ Date of last hemocult ____Nutritional History (how would patient describe diet?) Neurological: ____ Headaches _____ Loss of Consciousness ____ Tremor ___Memory Loss ___Numbness or tingling of extremities ____Head trauma ____ Weakness or Loss of Strength or Movement ____ Muscle Weakness or Increasing Weakness ____ Chronic Loss Bladder or Bowel Control ____ Family hx. Of Known Neuromuscular Disease (ALS, MS, or other) ____Problems with speaking ____ Can identify Time (year) ____Can identify persons _____Can identify place ____Counts backward by tens ____Can identify items Behavioral and Psychiatric: ___ Sad mood ___Difficulty sleeping ___Sleeping too much ___ Loss of appetite ___Loss of interest in occupation ___Difficulty keeping employment ___ Loss of interest in hobbies or recreation ___ Feelings of anxiety ___History of Depression ___History of psychiatric disorder ___Difficulty concentrating ___Difficulty learning new things ___High level of stress ____Difficulty in making or keeping relationships/friendships ____ Alcohol use (describe __occas. ___wkly in moderation ___wkly excessive, ____daily in moderation (glass of wine, etc.), ___daily excessive ) ____ Mood Altering Drug Use (___prescription or ___non-prescription) describe positives. Musculo-Skeletal ____Single joint pain (identify jt) ___ Multiple joint pain (identify jts) _____________________________ ___Joint swelling _____ Joint stiffness _____Neck Pain ____Previous bone density (result) ___Osteoarthritis hx. ___ Rheumatoid Arthritis hx. Or family ___ Lupus hx. Or family ____ Gouty Arthritis hx. Or symptoms ___Degenerative Joint Disease hx. ___Prev. Fractures ___ Hx Scoliosis ____Back Pain _____Prev. Back Injury ____ Hx bone/muscle tumors Cardiovascular ____ Chest Pain (location, radiation, exacerbation,) ___ Shortness of breath ___ Hypertension hx. ____Lipid (Cholesterol) disorder hx ____ Blood Clots hx ____ Edema of extremities ___Leg pain when walking ___Family hx Stroke (Embolic or Hemorrhagic) ___ Dizziness or Near Syncope ___ Previous Heart Dx, _____family hx Heart Dx. __ Heart racing/palpitations ___ Known Heart Murmur __ Hx of Rheumatic Fever ____Prev EKG, lipid profile, or other cardiac study (date) ____Prev. BP elevation Renal / urinary ____ Pain with urination ___Blood in urine ___Difficulty starting urination ___Small urine stream __Difficulty stopping urine flow ____Incontinence any time _____Flank Pain____ History Recurrent Urinary Tract Infections (bladder) ___ Previous Kidney Stone ____ History of renal or bladder cancer Genital / Reproductive / Sexual in both Men and Women: ____ Current discharge Vagina or Penis ___ Lesions on genitalia ____Prev. sexually transmitted disease or exposure, ____ Prev. test for HIV: ___Difficulty with intercourse ___Pain with intercourse ___ Infertility ____No. of sexual partners Sexual orientation: ___homosexual, ___ heterosexual, or ___bisexual Women: ___ No. of Pregnancies ___ No. of Live births ___No. of Miscarriages prior to delivery __No still births ____ No. planned Abortions ___ Age menarche__yes___no ___Regular Menses If none, age ceased: ____ Hot flashes Menses __heavy __light __monthly ___irregular ___ Date /result last pap smear____ CA125__yes __no Men: ___ Difficulty with erection ___Change is size of urine stream, ___Last prostate exam ___Last testicular exam ___Prior PSA if yes result: ____________ Breast Examine breasts regularly _yes __no Last breast exam by Doctor___ Date last mammogram Endocrine: ___ Heat or cold intolerance ___Fatigue _____Polydypsia or polyuria ____Fam. Hx of Diabetes ____Hair loss or changes ____ Edema ____ Weakness or extreme fatigue ____ Headache ____Growth changes Examining the Patient. The history and physical exam are followed by a physical exam. Do not forget to ask the patient if it is alright to perform the exam or to touch them. This keeps from alarming a patient or misinterpretation of an exam. Review your exams from your primary care course. In general remember not to listen through clothing. Remember this is not a time for shortcuts, when you listen to the heart, listen to all four areas. When listening to the lungs be sure to include all fields. Below is a description in general of each system exam. Remember to review the techniques from your primary care course and text. When Examining the: Be sure to evaluate: Head Hair pattern, skin lesions, palpation for lumps or bumps, cranium when indicated Eyes Visual fields, Eye movements, Lid function, Pupils, Anterior and Posterior compartments using Opthalmoscope Ears External ear, internal ear, and mastoid Nose Alignment and inner nare Mouth Tongue, teeth, throat, tone, tongue protrusion for neuro. Evaluate TMJ movement Neck Lymph nodes, mass, thyroid, carotids for bruits (cervical in msk) Chest Chest wall, chest excursion, heart – 4 points, lungs –post/ant. upper and lower fields. Examine axilla for mass. Evaluate ribs for motion in respiration and any tenderness. Abdomen Listen for bowel sounds and bruits first, examine all quadrants, check for pain, rebound, and guarding. Examine inguinal areas for mass Muscluloskeletal Evaluate posture and Gait. Joints – examine each for full range of motion and strength/stability. When focused (depending on complaint – visit examine the joint related to the complaint and the joint above and below as it evaluate fully or by area and relates to the joint. Look for edema, erythema, and tenderness. Evaluate for strength related areas) and muscle tone. Do not forget hands or feet where pertinent. Cervical spine- palpate and evaluate for full range of motion – flexion/extension/rotation/sidebending. Thoracic spine – palpate and evaluate for flexion, extension, side bending, and rotation. Evaluate related rib function. Lumbar and sacral – if one is to be evaluated, both should be. Include full range of motion, and in standing/sitting/lying positions. Evaluate gait and walking cycle. Look at key landmarks for evaluating leg length or pelvic rotation. When indicated be sure you know how to evaluate piriformis, sciatic patterns, and hip joint. Cranium – when/where indicated examine as for cranial abnormality. Neurological Alertness, orientation, mental status (include knowing mini-mental status) Know the exam for all cranial nerves. Examine for dysarthria, facial tone, tongue protrusion. Assure patient can name items, person, place, and time. Examine motor strength bilaterially. Examine sensory function bilaterally. Assure balance, finger-nose pointing ability, heel-shin/cerebellar functions. Examine any localized complaint fully. Remember the visual exam and hearing exam (and hx) always relate and are a part of the Neurological exam. Psychiatric Alertness, orientation, sad or depressed mood, signs of disorganized thought, dress, or other psychiatric clues. Formulating a Differential: Next formulate your differential diagnosis. What are the possibilities of diagnosis related to the history and your exam. Remember when using standardized patients, the history is often as important as your physical diagnosis when ruling in or ruling out certain disorders. In general you should have a minimum of three differentials for each complaint and up to five or more. You should be able to narrow to three or five most common by a good history and exam. THESE POSSIBILITIES COMPILE YOUR DIFFERENTIAL DIAGNOSIS, WHICH YOU WILL BE REQUIRED TO DOCUMENT. This may differ some in the COMLEX PE, where you may only have one or two diagnosis. In end of year testing we want to know the level of differential you can formulate – so we do require documentation of your Differential Diagnosis. Ordering Diagnostic Tests: Next to narrow your differential you may need to order certain diagnostic tests. You should always check with your patient to assure you have their agreement with these tests. The diagnostic tests possible during the exam include: Xrays, CT Scan, MRI, EKGs, and blood tests that will be available during an outpatient or ER visit. Remember you may need to assure that your patient has not allergies to die or that they do not have a pacemaker or other contraindications to tests such as a CT with contrast or a MRI. In general don’t go crazy with the tests. Defining a patient’s illness by eliminating all answers with expensive tests IS NOT CONSIDERED GOOD MEDICINE. Limit your tests only to those indicated or needed to narrow your differential. Don’t ever order a test if you don’t know what the test means! Remember if the test doesn’t answer an important question for you or narrow your diagnosis, don’t order it. (An example of this the unprepared student who orders a PSA on a female – yes it happens) During end of year testing: if you feel you need a test, after assuring you have the patient’s agreement, you may simply turn to the window and say “Assistant, could you order this exam for me”. Remember this is NOT to be done until your history and exam is complete and your differential has been made in your mind. AGAIN THIS IS NOT A PART OF COMLEX PE – THIS IS FOR END OF YEAR TESTING ONLY. When you take COMLEX PE be sure to read their website and the materials provided to you for NBOME instructions. In end of year testing, once you have requested a test, soon the technician will bring you the test results or some other note may be handed to you. The possibilities that exist are: o If the test is not appropriate we will tell you the machine is broken or it will be done tomorrow. o If the test is appropriate but not available for this case – or case timeframe we will tell you it will be done tomorrow. o If an alternate test is just as good and is the result we have, you will receive a message that the machine is broken. but we did text X instead. In most cases if the test is appropriate, you will receive the result in a report or the test result for you to interpret. The Medical Record You will be required to write a complete legible patient note in nine minutes. You will use a SOAP note style. S: The note must include the subjective section which is the chief complaint, the history of the chief complaint, pertinent positive and negative historical findings, and a review of the pertinent systems that relate to your potential diagnoses. O: The objective section should include your physical finding – both pertinent positive and negative related to exploring the chief complaint. A: Assessment should include: Differential Diagnosis: 1., 2., 3., and/or more. When you formulate your differential diagnosis, you should discuss your assessment with your patient prior to ordering the diagnostics, explaining the diagnostics as they relate to your differential, and assure the diagnostics are okay. Example of how your note might look for a patient who reports blood in their stool. Differential Diagnosis Melena: 1. Possible GI bleed due to ulcer disease, 2. Possible cancer, 3. Possible hemorrhoids Record your Diagnostic Findings here: Hemocult and rectal exam were negative, CBC demonstrated anemia, possibly secondary to blood loss. Finally if you reach a diagnosis from the history, exam, differential and diagnostic tests, you may record: the Primary Diagnosis here. You may also record any secondary Diagnosis here as well. Depending on the case, you may have to have the differential be your assessment with the diagnostics to be in your plan. P: Now record your Plan: This includes any further diagnostics you may need and one or more of the following: OMT, Medications, Surgery, Physical therapy or other ancillary treatment, and/or Appropriate consult. Be sure to okay this plan with the patient and tell the patient why/what you are treating. Be sure to arrange for follow-up appointments or evaluations where needed. Remember when taking your exam, you will have an equal opportunity through standardized cases to demonstrate: Clinical Knowledge, Communication, Critical Thinking Skills, and Technical Skill. A videotape monitoring system documents each encounter and ensures the safety of the patients and candidates. If you do not pass your exam, you may review the tape while in remediation. The cases will also help to prepare you for COMLEX PE. CONTENT OVERVIEW Clinical Chairs and Clinical Faculty write and review cases to ensure quality and consistency in education. The cases are designed to elicit a process of history taking and physical examination that demonstrates your ability to list and pursue various possible diagnoses. The cases that make up each Standardized Patient reflect a balance of a mix of acute, sub- acute, and chronic problems as well as preventive medicine. The cases at the end of the year exam are developed by the faculty from your clinical departments from the discipline objectives. The Standardized Patient Cases may include cases from: 1. Pediatrics 2. Family Medicine 3. Internal Medicine 4. Psychiatry 5. Obstetrics/Gynecology 6. Geriatrics 7. Emergency Medicine 8. Surgery 9. Underserved Care DESCRIPTION OF THE STANDARDIZED PATIENT EXAMS Standardized patient exams last 14 minutes with nine minutes of medical record writing. OSCE exams (to be discussed later in this document last 18 minutes each including all questions and writing. The following information will be useful in this process. Standardized Patient Exams: Before entering each examination room, you will have an opportunity to review information posted in the patient chart. You will also receive specific instruction that indicate the patient’s name, age, gender, and the reason for visiting the doctor. You should confirm this information when entering the room. Any additional information given on this chart as to vital signs or laboratory results, you can accept as accurate and do not need to repeat unless you believe the case specifically requires it. When you enter each room, you will encounter a standardized patient (SP). You should perform a focused history, review of systems, and a focused physical examination based on the complaint. A focused physical exam and review of systems means the system obviously affected and the systems needed in narrowing your differential. It is rarely one system you would review and most complaints require the review of a minimum of three systems. Examples are given at the end of this section. In the history and review of systems you should be able to gather enough information to develop a preliminary differential diagnoses and focus on areas where you need to conduct your physical exam. Utilizing the history, review of systems, and physical exam you should be able to formulate a differential diagnosis and a diagnostic evaluation (diagnostic plan). You should inform the patient of your findings, the differential diagnoses (plural) you are considering. You should explain your diagnostic workup plan and assure it is okay with the patient to conduct. You will also be expected to communicate with the patients in a professional and compassionate manner, and explain each item to them . You should stop often to ask and answer if any questions exist. Please make eye contact. The elements of medical history you need to obtain in each case will be determined by the nature of the patient’s complaints. Not every part of the history-review of systems, needs to be taken for every patient. Some patients may have acute problems, while others may have more chronic ones. You probably will not have time to do a complete physical examination on every patient, nor will it be necessary to do so. Pursue the relevant parts of the examination, based on the patient’s problems and other information you obtain during your interview. The key to interacting with a standardized patient is to relate to them exactly as you would any patient with this complaint. Do not treat this as a test, but as a normal clinical encounter. You will have fourteen minutes for each patient encounter. The patient encounter begins with your review of the chart. An announcement will tell you when to begin the encounter. There will be a tap on the window when there are two minutes remaining for your exam. If there is laboratory or diagnostic labs available there will be a note that diagnostic data exists. AFTER YOUR EXAM AND A DIFFERENTIAL IS MADE, IF YOU FEEL A TEST IS INDICATED THAT MAY BE DONE IN THE OUTPATEINT SETTING YOU MAY ASK FOR IT AT THE WINDOW. “ I will need a CT Scan” If it is available and if it is appropriate you will receive the results. If it is not available it will be ordered for tomorrow. Note do not become upset if a test is not done, it may be appropriate and interpretation may simply not be a part of this SP encounter. If it is not available you may still include this in your plan. You must request the specific test to receive it. There will be a final tap when the encounter is over. At this time you will then be notified you have nine minutes to complete your chart/patient note. If you leave the encounter early, you may use the additional time for the patient note, however it is most important to be complete in all elements. You will be asked to write a patient note similar to a medical record you would compose after seeing a patient in an ambulatory clinic or emergency room setting. This will not be an ER setting unless you have the information it is an ER setting. You should record all pertinent medical history and physical examination findings, as well as your initial differential diagnoses. Finally, you will list the diagnostic studies you wish to order on that particular patient. Consultations may be included however a simple consult does NOT take the place of an evaluation plan or knowledge of treatment. IF you obtain a consult, you must say what the consult is for. For example if you have a patient with a suspected appendectomy you must say surgical consult for possible appendectomy. IMPORTANT: The majority of cases are designed to present more than one diagnostic possibility in the Differential. The differential you develop should be based on the patient’s presenting complaint and the additional information you obtain taking the history, performing the exam, or from data on the chart. You should consider all possible diagnoses within the differential and explore the relevant ones as your time permits. You should perform physical examination maneuvers correctly and expect that there will be positive physical findings in some instances. Some may be simulated by the patient, but you should accept them as real and factor them into your evolving differential diagnoses. Always be considerate of your patient, and always keep them comfortable, properly informed regarding the examination you are doing on them, and properly draped as you perform the physical examination. You should always wash your hands before beginning the physical examination. These encounters mimic some of the COMLEX PE testing. A rectal, pelvic, genitourinary, female breast, or corneal reflex examination are never performed on standardized patients in this venue. If it is required at this visit you will be given a card if and when you request the particular exam. OBJECTIVE STRUCTURED CLINICAL EXAMS (OSCE) You will have six OSCEs, scheduled for 18 minutes each. There are three OSCEs per hour so you must transition from room to room in an efficient manner. Everything you need to perform the OSCE will be in the room. The OSCEs may or may not include a standardized patient. When the OSCE includes a standardized patient, you will be requested to perform a specific task on the standardized patient, not a complete encounter. One OSCE includes the simulated emergency cases, the use of the the ER SIM model and other simulated models. The ER SIM exam is perhaps the most challenging and you should be prepared with the basic ACLS skills and EKG recognition. Other examples of OSCEs include a pediatric OSCE that may ask preventive medicine and health maintenance assessments and managment, or a typical OB/GYN case with a model pelvis. These are to test your knowledge and clinical skills and do not mimic the COMLEX PE. GRADING BY STANDARDIZED PATIENTS Standardized patients will document some of your assessment. SPs are trained to assess and document your performance immediately following the encounter. This is part of the SP training and uses a yes-no answer. In addition, patients may comment on your performance, however comments unless unethical or unprofessional behavior do not factor into the pass or fail of the station. Each SP completes a checklist that documents your performance during the patient encounter. GOING OUT OF CHARACTER WITH A STANDARDIZED PATIENT IS CONSIDERED UNPROFESSIONAL BEHAVIOR AND WILL RESULT IN YOUR HAVING TO RETURN AT A LATER TIME TO COMPLETE YOUR EXAM. ALWAYS MAINTAIN A PATIENT-PHYSICIAN ENCOUNTER ROLE. GRADING BY FACULTY Faculty physicians also grade your encounter. The grading includes a checklist of all key questions and examinations. The checklist has only two options: performed correctly: yes or no which includes not performing or performing incorrectly. Faculty also grade your soap note. This is a most challenging task. You should not abbreviate in your note, as abbreviating is now considered a risk factor for patient errors. It is your responsibility to be legible in your handwriting. If we can’t read it, you didn’t ask or it didn’t happen. Case Objectives and Competency Based Evaluation Form for full Standardized Patients HUMANISTIC: 1. Case Objective 1: Professionalism: The student demonstrates the ability to professionally introduce self, has professional dress and appropriate hygiene and introduces self and verifies patient, and washes hands. Performed: ____yes ____no 2. Case Objective: Professionalism and empathy: The student demonstrates the ability to place his/her patient at ease, explaining all exams, assuring permission to touch, asking if any questions. Performed: ____yes _____no 3. Case Objective: Communication skills and empathy: The student maintains good eye contact through most of the exam, listens to patients questions, picks up on clues such as mood, anxiety, pained expression and maneuvers, and questions related to worry. Performed: ____yes ____no 4. Case Objective: Compassion: When giving a concerning diagnosis or test result the student assures the patient understands the test or differential and reassures the patient against over-concern. The student exhibits empathy and explores if the patient would want to discuss any historical information of concern such as a child’s or spouse’s death. Performed: ____yes ____no 5. Case Objective: Patient Partnering: The student can convey and assures the patient understands the main differentials in the diagnosis, and that the patient understands and is in agreement with any tests ordered. Performed: ____yes ____no 6. Case Objective: Patient Partnering: The student assures the patient is in agreement with the plan at the closure of the visit, that the patient understands all components of the treatment plan, that the patient is told of the most common things to watch for with a medication if prescribed, and that the patient understands consults if made, the follow-up plan, visits, etc. CLINICAL SKILLS 7. Case Objective: Medical History The student elicited the Chief Complaint – including onset, duration, exacerbating and alleviating factors, hx of prior same symptom, what brought the patient in today, and if pain scale of 1-10, and any prior treatment attempted for this complaint. Performed: ____yes ____no 8. Case Objective 3: Medical History The student demonstrates the ability to elicit and explore a patient’s family history, work history, social history, psychological history, and risk factors. Performed: ___yes ___no 9. Case Objective: Medical History The student explored the appropriate review of systems related to the chief complaint ( the system related to the chief complaint and at least the pertinent systems (generally one or two additional systems) Performed: ___yes ___no 10. Case Objective 4: Medical History: The student demonstrates the ability to determine the Past Medical History, Surgeries, Injuries, Current Medications, Allergies, and Medication Intolerances Performed: ____yes ____no 11. Case Objective 6: Physical Exam: The student performed the physical exam of the system related to the chief complaint in the appropriate manner. Performed: ____yes ____no 12. Case Objective: The Physical Exam: The student performs a complete and appropriate examination of the secondary system related to the chief complaint. Performed: ____yes ____no CLINICAL DIAGNOSTIC REASONING AND MEDICAL KNOWLEDGE (FROM SOAP NOTE – 6 of the following 9 should be used depending on case. The total number in this section is 6 coming to a total of 18 evaluation points.) 13. Case Objective: Critical Thinking: The student documents an accurate Differential Diagnosis (minimum of three): Performed: ___yes ____no 14. Case Objective: Diagnostic Reasoning: The student orders and documents the significant diagnostic tests to order to explore the differential. Performed: ____yes ____no 15. Case Objective. Diagnostic Reasoning: The student can interpret the diagnostic tests ordered when test results or films are given (dependent on case/case author) Performed: ____yes ____no 16. Case Objective. Critical Thinking: When given the appropriate information, the student can narrow the diagnosis to a probably cause. (optional according to case given) Performed: ____yes ____no 17. Case Objective: Documentation of the Plan: The appropriate treatment plan was documented including all major therapeutics indicated. Performed: ___yes ___no 18. Case Objective: The appropriate consult with a reason for consult was made and documented. (Optional, depends on case or case author) Performed: ___yes ___no 19. Case Objective: OMT The student recognized the need for OMT and documented the appropriate OMT to be performed. (Optional depends on case or case author) Performed: ___yes ___no 20. Case Objective: The student documented the appropriate consultant to be used and what the consultant was to be used for. (ie: surgeon for appendectomy, or neurology consult for seizure evaluation, or cardiologist for evaluation of ischemic heart disease) Performed: ___yes ___no 21. Case Objective: Preventive Medicine The student evaluated the patient’s health and wellness through assessing risk factors, assessing whether the patient had appropriate immunizations and screening exams, and where appropriate gave advice on preventive measures such as diet, exercise, routine pap smears and breast exams, mammography, colonoscopy, and laboratory exams such as glucose and lipids if indicated by hypertensive states, family history, etc. Performed: ___yes ___no IMPORTANT KEYS TO SUCCESS Dress like a physician and Conduct yourself as a physician. A white coat is not all you need and flip flops, jeans, etc. just will not be acceptable. This is not a lab. Standardized patient cases require the consideration of multiple diagnosis in your differential diagnosis the majority of the time (seldom less than three and up to five). Do not skip steps in the history or exam by coming to a premature conclusion. Do not base your diagnostic plan on a single diagnosis. Do not skip any part of the physical exam that may be pertinent to a complaint. Do not do a partial exam of any area: ie: only listening to the lungs in two areas, only listening to the heart in one area, listening through the gown, etc. all of these will result in a no: performed incorrectly finding. You should attempt to elicit important positive and negative signs in your exam as the patient has been trained to mimic these. Be sure you discuss with the patient your initial differential and your diagnostic evaluation and why you are doing each test. Standardized patients are instructed to ask questions of you concerning their visit and they may be challenging. treat the SP as you would any patient who would inquire information from you. Be sure to perform the examination in the same manner you would with a real patient in a clinical setting. Pay attention to the setting as that will indicate what resources are available to you. (A family physicians office may only have lab or xray while an ER has access to CT scans). Do not palpate overly aggressive in order to elicit a finding that you believe should be there as it may not be there, and the appropriate gentleness of a normal exam is expected and evaluated by the patient. If during the visit you determine that a rectal, pelvic, genitourinary, female breast or corneal reflex examination is necessary for evaluating and treating the patient, place it in the diagnostic plan. If there is a concerning diagnosis in your differential you must explain this is a caring and considerate manner, example such as: “We will have to rule out any tumors here, but there are many other diagnoses such as the others I have told you. So let us find out what it is before you worry too much about that” This is just an example of putting a patient at ease, you may have many such examples of your own. END OF YEAR EXAM The end of year exam is a three to four hour exam written by your clinical faculty. These are submitted in equal number by your clinical chairs. Second year end of year exam is from the Chairs based on your clinical knowledge from Pathology and Clinical Case Correlations. For the end of third year exam, some will come from your end of rotation exams and some are from a test bank. All contain the knowledge required of you at the stage you are in (second or third year). You are required to pass the exam. Although there is a curve used for the exam, you will receive both the raw score and the curve score. The grades are recorded as pass, high pass, and honors. Note, you must pass the exam to move to the next year. There is no way to prepare for this exam at the last moment, it is a two to three year process depending on the exam. The results may give you some indication of how you will do on boards. USE OF OMT DURING SP AND OSCE TESTING While Standardized Patient exams at VCOM require a full osteopathic evaluation, the SP will not require that a student perform osteopathic manual treatment or therapy on the patient. (recognize a standardized patient cannot receive 50 treatments in 3 days). If OMT is indicated the student should explain OMT to the patient, assure it is okay to perform OMT, and document the OMT to be performed in his or her treatment plan. The student should in communication say something like: “I believe you would benefit from an OMT treatment” – explain the treatment to be used on the patient – assure the patient agrees with the treatment and state that the patient will be moved to an OMT room for treatment later. The description of the treatment is documented in the medical record. This relates to end of year testing and not to the COMLEX PE. You must follow COMLEX PE instructions when you are there for this one. While OMT is not performed in SP patients, OMT may be required of you during an OSCE test. This will be a specific exam or a specific treatment when required. In an OSCE the exam must be performed and documented appropriately.
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