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Date:  Student Name:  Reviewer (SP):

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Communication Behaviors Not Done or Needs Improvement Meets

SS1

Introduces self

Name and title not stated

Name and title stated

Introduction of others

Not asked

Asked for name(s)

Establishes patient priorities

Not done

Done

Negotiates an agenda

No agenda, time, or purpose stated

States time needed

SS2

Initial impression

Unwelcoming/unhelpful attitude

Welcoming and helpful attitude

Voice quality, tone, and pace

Does not enhance conversation; difficult to understand and/or follow

Enhances conversation

Medical jargon

Terms not easily understood

Uses everyday language

Nonverbal communication

Detracts from interaction

Neutral or enhances interaction

Eye contact

Detracts from interaction

Neutral or enhances interaction

Empathy

Detracts from interaction

Neutral or enhances interaction

Attentive and reflective listening

Does not listen to me, interrupts

Makes me feel heard

Attire, personal hygiene, and grooming

Detracts from interaction

Neutral or enhances interaction

SS3

Assesses patient understanding

None/closed-ended

Open-ended questions used

Elicits final questions

None/closed-ended

Open-ended question used

Closes encounter and offers support

Not done

Supportive statement and shows pharmacy telephone number on label

If you were a patient/customer, would you come back to this pharmacist? □ Yes □ No

COMMENTS (to be completed by SP)

  1. Please provide general feedback on what it was like to be the student’s patient (eg, “As your patient, I felt heard when I told you that I was concerned about the side effects, and you made sure to spend extra time explaining them.”).

  2. If you indicated that you would not return to this pharmacist, please clearly explain why.

  3. Please list at least one thing the student could improve for future encounters.

  4. Please list at least one thing the student did well during the encounter.

  5. Additional comments:

*Communication rubric created by Krista Salazar, PharmD, University of New Mexico College of Pharmacy. Counseling rubric skills adapted from: Chou CL, Cooley L. Communication RX: Transforming Healthcare Through Relationship-Centered Communication. New York, NY: McGraw-Hill Education; 2017.

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