HIV AIDS Fellowship Program

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					                          Clinical Officer Assessment Tool

                  Provider: ___________________________________ Site: _________________
                  Supervising Physician:_______________________ Month/Year:___________

Please summarize Provider’s skills using codes given below:
1 – Poor: Not demonstrated / very poor demonstration of skills- needs complete/full training
3 – Satisfactory: Demonstrates some strength/skill in area – needs to strengthen skills in some areas
5 – Good: demonstrates excellent strength/skill in this area –

Please use the ―comments‖ column to note key observations to be discussed later with the provider. In addition, this
space should be used to record explanations for why recommended practices were not followed, to describe instances
where the provider was particularly effective and/or to note particularly useful advice provided by you to the provider.

    Demonstrated Skills/Tasks              1=Poor               3=Satisfactory              5=Good               Code Assigned –
Initial Assessment
 Chief complaints asked             Chief Complaints- problems, which are of immediate, concern to patient.
                                     1—No questions asked.
    and recorded including the
                                     3—Questions asked, but only related to positive symptoms, some patients
    duration of the problem.         5—Questions asked relating to both positive and negative symptomatology
                                     all patients
    Present Medical History is      Present Medical History –
                                     1—Elaboration of chief complaints only
     taken -sequential, relevant
                                     3—Sequential, chronological elicitation of symptoms using open ended &
     to chief complaints and they    close ended questions, some patients.
     are recorded                    5—Symptom analysis, positive & negative symptoms, all major systems
                                     (CVS, RS, Abdomen, CNS) covered, all symptoms analyzed in chronological
                                     order, all patients
    Past Medical History is         1—Limited to chief complaints only, not dealing with co morbid medical
     taken, relevant to chief        complaints
                                     3—Co morbid medical conditions (diabetes, asthma, epilepsy, tuberculosis)
     complaints, co morbid           enquired into, past symptoms related to relevant symptoms, some patients
     medical conditions, previous    5—Co morbid medical conditions, along with previous surgical conditions,
Clinical Officer’s Assessment Tool                                                                                      Page 1 of 10
                                                        I-TECH Clinical Mentoring Toolkit
    Demonstrated Skills/Tasks                 1=Poor               3=Satisfactory               5=Good             Code Assigned –
     surgical procedures, blood  blood transfusions, and drug allergies recorded, all patients.
     transfusions and drug
     allergies recorded.
    Family History is taken and 1—Limited to details of individual patient marital status
                                 3—Details of marital status, current partner status (wife/husband, keep),
                                       children and parents (grand parents if AIDS orphans)
                                       5—Details of co morbid medical conditions, genetic disorders in all
                                       generations, in addition to above, all patients.
  Drug history is taken               1—Limited to current medication, with some previous medication details
   comprising current, previous        3—Current & recent past medications, dosage & duration elicited, some
   medication, side effects,           5—Toxicity, side effects, compliance & adherence elicited in addition to
   toxicity, allergy, and              above, all patients.
 Personal History taken        1—Limited to diet history, no personal habits enquired
                                3—Details of smoking (type, number, duration), alcohol consumption (type,
   with emphasis on diet,
                                amount, duration), chewing tobacco, some patients
   addiction habits (smoking,   5—Addicting drugs (I.V/smoke) in addition to above, all patients.
   alcohol, narcotics etc)
 Sexual history taken,         1—History of exposure elicited, no privacy or confidentiality
                                3—Details of sexual exposure (pre marital, extra marital), history of STI’s
   previous and current STI’s,
                                and treatment given (previous/current genital ulcer, discharge, bubo etc.),
   contraception use, partner   5—Use of barrier contraceptives, same sex preferences elicited with route of
   notification issues in       penetration (anal, oral), privacy(utilises side room) & confidentiality (informs
   empathetic, confidential     patient history is confidential) maintained with non judgemental attitude
   setting.                     (empathetic, body gestures), all patients.
 Documentation accurate,       1—Documentation not done,
                                3—Partially complete or complete documentation of all findings, some
   complete, and timely for
   every consultation including 5—Documentation complete, all patients
   completion and appropriate
   medical forms.
Professional/ Interpersonal Skills
 Patient Centered (Listens     1—Welcomes the patients & offers seat to patient
                                3— Body language appropriate, empathetic (listens to patient), some
   to patient’s ideas and
   concerns) -                  5—Open ended questions, encourages patient, - all patients
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                                                           I-TECH Clinical Mentoring Toolkit
    Demonstrated Skills/Tasks                 1=Poor                3=Satisfactory                   5=Good             Code Assigned –
  Timely (doesn’t rush patient 1—No/ limited time spent
                                3— Adequate time 5-10 minutes, for some patients
   and doesn’t take too much
                                5—Adequate time for all patients.
 Privacy and                   1—No/limited elicitation of sensitive history/risk taking behaviour
                                3—Elicits sensitive history using appropriate open ended and close ended
   confidentiality is
                                questions, in some patients
   maintained while taking      5–Elicits sensitive history in all patients utilising side room (privacy) for all
   sensitive histories.         Explains to patient how confidentiality is maintained.
 Uses team approach            1—Limited/no co ordination /communication with team members,
                                3—Consult specialist physician when needed, handles phone consultations,
   (shares information with
                                instructs staff nurses, in addition to above.
   nurse, counsellor, social    5- Organises support systems, mentors colleagues
   worker, nutritionist, and
   pharmacist for an efficient
   interaction, lack of
   duplication of effort)
 Practices universal           1—Limited /no advise on infection control measures to patients
                                3—Advises on cough hygiene, hand washing, use of gloves for individual
   precautions and advises
   on post exposure             5—Ventilation adequate, segregation/disposal of waste –interaction with
   prophylaxis, infection       nursing assistants/sanitary workers, supervises & performs infection control
   control procedures in work- procedures
Clinical Examination & Assessment
 Vital signs record and &      1—No /limited recording of some vital signs in few patients.
                                3—Recording of all vitals (temperature, respiratory rate, blood pressure,
   comfort of patient at rest.
                                       pulse) in some patients, using appropriate method
                                       5—Recording of all vitals in all patients, with identification of patients not
                                       comfortable at rest.
    Weigh patient accurately &        1—Limited/no recording of weight
                                       3—Recording of weight some patients
     calculate percentage of
                                       5—Recording of weight/calculation of BMI all patients.
     weight gain/loss
    General examination               1—No/limited examination
                                       3—Looks for anemia, clubbing, jaundice, cyanosis, skin, hair, nails etc in
     adequate including
                                       some patients
     examination from head to          5—Thorough general examination, with privacy (eg.female patients –side
     toe, looking for signs of         room) –all patients.
Clinical Officer’s Assessment Tool                                                                                             Page 3 of 10
                                                            I-TECH Clinical Mentoring Toolkit
    Demonstrated Skills/Tasks               1=Poor               3=Satisfactory                5=Good                 Code Assigned –
     internal disease.
    Lymphadenopathy, oral           1—Limited /no checking of groups of lymph nodes, oral cavity and hydration
     cavity, hydration status        status.
                                     3—Examines all groups of lymph nodes, entire oral cavity and hydration
     recorded and verified           status for some patients, with proper methodology.
                                     5—Abnormalities of nodes (number, size, matted, sinus etc)/ oral cavity/
                                     hydration clearly defined and communicated in addition to above.
    Systemic examination –          1—Limited /no use of stethoscope –uses diaphragm, but not bell in
     Cardiovascular system           appropriate circumstances, through clothing
                                     3—Inspection & palpation of apical impulse, arterial/venous neck pulsations,
                                     appreciation of heart sounds & palpable murmurs, auscultation of heart
                                     sounds & murmurs, measures jugular venous pressure, some patients.
                                     5—In addition, feels all peripheral pulses, notes rhythm irregularities, all
    Systemic examination –          1—Limited to upper respiratory tract examination –sinus tenderness, tonsillar
     Respiratory system              enlargement etc.
                                     3—Inspection & palpation of tracheal position, vocal fremitus, chest wall
                                     movements, percussion of chest, auscultation of breath sounds.
                                     5—Identification of abnormal (bronchial) breathing & additional sounds
                                     (rhonchi, crepitations), respiratory failure, in addition to above.
    Systemic examination-           1—Inspection of abdomen
                                     3—Palpation of abdominal quadrants systematically (including scrotum &
                                     testis in male patients), identification of organomegaly, masses, free fluid
                                     (using appropriate methods), per rectal examination (when appropriate)
                                     5—Auscultation of bowel sounds, identification of acute abdomen
    Systemic examination –          1—Limited/no examination of genitalia
                                     3—Inspection/palpation of male/ female external genitalia.
     genital examination
                                     5—Insertion of sterile proctoscope /vaginal speculum (when available) in
                                     privacy (side room)
    Systemic examination –          1—Limited/ no examination
                                     3—Examination of higher functions, cranial nerves, motor system (power,
     CNS, peripheral &
                                     tone, reflexes), sensory system, cerebellar signs, neck stiffness (brudzinski,
     autonomic systems               kernig’s sign)
                                     5—Optic fundus, nerve thickening, gait examined in addition to above, all
Clinical Diagnosis
 Check written /                    1—No/limited checking
   documentation of positive         2—Checking some patients

Clinical Officer’s Assessment Tool                                                                                           Page 4 of 10
                                                         I-TECH Clinical Mentoring Toolkit
 Demonstrated Skills/Tasks                  1=Poor               3=Satisfactory                5=Good             Code Assigned –
   HIV test serology for index       3—Checking all patients
   case and contacts
 Recognises and makes               1—No/limited recognition of symptoms
                                     3—Provisional /differential diagnosis relevant to presenting symptoms and
   provisional / differential
                                     signs of patient leading to diagnosis of opportunistic infections.
   diagnosis of presenting           5—Diagnoses co morbid medical conditions, other medical/surgical/obstetric
   symptoms leading to correct       complications in addition to above.
   diagnosis of opportunistic
   infections/ concurrent
   medical/ surgical/ obstetric
 Determine TB clinical              1—No/ limited determination of TB status
                                     3—Determines current/previous status using Sputum positivity, chest
   status & respond
                                     skiagrapy & DOTS card, some patients
   appropriately, including          5—Determines current/previous status all patients.
   referral to DOTS Centre
 Determine accurate Clinical        1—No/limited staging of few patients
                                     3—Staging of some patients
   Staging using W.H.O.
                                     5—Staging all patients – with record of criteria upon which staging based,
   definition and record             every visit.
   whether based on clinical
   criteria (current or prior) or
   total lymphocyte count or
   CD 4 count.
Laboratory Assessment
 Evaluate patients with             1—No/limited use of tests
                                     3—Uses protocol/algorithmic approach some patients
   complications using
                                     5—Uses protocol/algorithmic approach all patients with complications.
   laboratory tests as
   appropriate & to confirm
   the clinical provisional
 Check results of laboratory        1—No / limited verification
                                     3—Verification, documentation some patients with appropriate response
   and verify documentation,
                                     5—Verification, documentation, response adequate all patients.
   interpretation of results
   correctly leading to
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                                                         I-TECH Clinical Mentoring Toolkit
 Demonstrated Skills/Tasks                  1=Poor               3=Satisfactory                 5=Good          Code Assigned –
   appropriate response.
 Uses CD4 count, viral load         1—No/limited use of tests
                                     3—Uses tests in some patients some times, not regularly
   and Total Lymphocyte
                                     5—Uses tests in all patients at specified times, according to protocol
   count, to determine
   medical eligibility for
   antiretroviral therapy, when
   appropriate, and staging of
   HIV infection
Clinical Care & Treatment
 Knowledge base is                  1—No /limited care plan
                                     3—Care plan drawn up for some
   adequate to provide safe
                                     5—Care plan drawn for all patients
   and complete care of
 Decide what clinical care          1—No/limited in decision making for patient care
                                     3—Some patients may be treated partially
   to provide after the
                                     5—Complete attention to all patient’s needs and gives directions
   assessment is complete
   using WHO clinical staging
 Recognise when persons             1—No/limited action
                                     3—Action in some patients, not complete
   need acute care for life
                                     5—Appropriate complete measures.
   threatening complications
   and admit /provide first aid
   immediately in accordance
   with the Hope Clinic
   Hospitilisation Policy.
 Treat /stabilise                   1—No/limited intervention, incorrect dosage, duration
                                     3—Treats according to algorithm, correct dose, duration, some patients
   opportunistic infections
                                     5—Treats according to algorithm, correct dose and duration, appropriate
   and STIs by following             instructions, all patients
   national guidelines, using
   available formulations,
   correct drugs and dosage.
 Manages other common               1—No/limited management of other chronic illness.
                                     3—Manages chronic illness/co –morbid conditions, according to guidelines
   chronic illnesses (in
Clinical Officer’s Assessment Tool                                                                                     Page 6 of 10
                                                         I-TECH Clinical Mentoring Toolkit
    Demonstrated Skills/Tasks               1=Poor              3=Satisfactory               5=Good              Code Assigned –
     addition to opportunistic       5—Seeks specialist advice in addition to above.
    Determines TB Clinical          1—No/limited intervention
                                     3—Categorises disease and advises appropriate regimen
     status and responds
                                     5—Refers, follow up in addition
    Knows when to seek              1—No/Limited willingness to seek guidance
                                     3—Asks for some patients who need senior opinion
     guidance from supervising
                                     5—Ask for all patients who need senior opinion
    Exhibits proficiency in         1—No/Limited knowledge on looking up issues
                                     3—Shows some level of proficiency to look up issues
     researching medical
                                     5—Knows how to look up and where to get clarification on important issues
     information related to care.      in a book/journal/newsletter/website
Opportunistic Infection Prophylaxis
 Manages co-trimoxazole         1—No / limited issue of co-trimoxazole
                                 3—Uses co trimoxazole at correct stage in correct dosage.
   prophylaxis, initiates at
                                 5—Identifies / monitors drug side effects, prescribes alternatives (dapsone)
   correct stage, manages side in allergic patients, checks compliance and follow up dates for next issue.
   effects, prescribes
   alternatives, discontinues at
   proper time, checks
   compliance, follow up
 Manages fluconazole            1—No/limited use of fluconazole, used at inadequate doses or inappropriate
   prophylaxis, initiates at     routes
                                 3—Uses fluconazole correct dosage, duration and route
   correct stage, dosage and     5—Identifies/monitors drug side effects, alternatives in allergic patients,
   duration adequate,            checks compliance and follow up dates for next issue, discontinues when
   manages side effects &        appropriate
   discontinues at proper time
Nutrition Advice / Drug Side effects
 Describe local sources of      1—No/limited advice
   nutritious food, drug- food   3—Advises on local sources of nutritious food, manage common side effects
                                 of drugs
   interactions if any, and      5—Advises on drug-drug interactions, drug –food interactions if any,
   address adherence issues      emphasises on adherence related to meals
Referral to HAART Protocol

Clinical Officer’s Assessment Tool                                                                                      Page 7 of 10
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    Demonstrated Skills/Tasks               1=Poor               3=Satisfactory                5=Good             Code Assigned –
  Discuss patients interest in      1—No/limited discussion
                                     3—Discusses reasons for initiation / delay in starting ARV therapy,
   ARV therapy, discuss
                                     adherence issues some patients
   reasons for initiating or         5—Discusses reasons for initiation/delay in ARV therapy, adherence issues,
   postponing ARV treatment,         all patients.
   explains benefits/risks of
   ARV, prepares patient
   supporters for adherence.
 Explain to patients medical        1—No/limited discussion/verification of patients clinical stage
                                     3—Verifies patients clinical stage & advises patients accordingly
   / programme criteria used
                                     5—Refers patients to ARV outpatient department, after social/family
   to select people for ARV          counselling
   therapy, verifies patients
   clinical stage of HIV
   infection (based on CD4
   count/WHO staging) and
   refers to HAART for
   preparedness counselling.
Follow Up
 Advises on clear plan for          1—No/limited care plan
                                     3—Care plan for some patients
   individual patient &
                                     5—Care plan, all patients, every visit as per Hope Center protocol.
   allocates dates for follow up
 Seeks specialist advice in         1—No/limited referrals made
                                     3—Co-ordinates with team members, fixes specialist advice
   situations of special need
                                     5—Interacts with specialist, and follows up outcomes
   (Ophthalmic, obstetric,
   psychiatrist etc), with
   referral linkages and
   communication issues dealt
 TB DOTS referral for all           1—No/limited referral to DOTS centre
                                     3—Referral to DOTS centre, some patients
   New TB cases diagnosed,
                                     5—Referral to DOTS centre, all patients, and follows up outcomes
   at district level

Areas for Improvement/Current Challenges:
Clinical Officer’s Assessment Tool                                                                                       Page 8 of 10
                                                         I-TECH Clinical Mentoring Toolkit
Action Plan for Person to Improve Identified Areas for Improvement:

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                                          I-TECH Clinical Mentoring Toolkit
Person conducting Assessment: ____________________________
Suggested Date for Next Assessment: _______________________

Clinical Officer’s Assessment Tool                                       Page 10 of
                                     I-TECH Clinical Mentoring Toolkit