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Student Name: __________________________________ Evaluator: _____________________________

Please give feedback on the following components. Any categories scored as “needs development” or “needs significant development” should include suggestions for the student to improve.

Confident and Consistent

Student clearly demonstrates confidence and skill consistent with an appropriate level of interaction with the patient.

Needs Development

Student is missing a few of the elements necessary for an appropriate level of patient interaction.

Needs Significant Development

Student is missing many of the elements necessary for an appropriate level of patient interaction.

While many details exist within the rubric, the grading (and overall focus of your feedback) will center around these activity objectives:

  1. Communicate with transgender and gender-nonconforming (TGNC) patients in an inclusive and affirming manner.

  2. Practice using gender-neutral pronouns and terms of address.

  3. Practice general counseling points for transdermal patch use.

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Encounter Component Confident and Consistent Needs Development Needs Significant Development



• Introduced self (name and position)


• Greeted the patient

 • Asked patient’s preferred name

 • Avoided gendered terms when addressing patient (sir, ma’am, Mr./Mrs.)


• Established patient's identity using a secondary identifier


• Obtained patient's chief complaint/concerns


• Described the purpose of the encounter



Reviews information for safety and introduces the medication


• Asks about drug allergies, adverse drug reactions, AND reviews current medications (Rx, OTC, herbal/supplements)


• Indicates name, dose, dosage form, and indication for medication



Explains how to take the medication


• Explains entire dosing regimen (ie, how many, how often), including administration, special dosing requirements, and missed dose instructions


• Explains appropriate storage conditions AND refill information (must include patch disposal)



Explains what to expect from the medication


• Discusses common AND important side effects, as applicable

 • Focused on potential issues with using the patch itself and/or undesired effects of the medication



Verbal and nonverbal communication skills


• Used an appropriate pace and volume of speech along with correct language and pronunciation


• Avoided filler words (um, uh, like)


• Made appropriate eye contact


• Displayed professional demeanor through attire, grooming, body language, and confidence


• Avoided medical terminology



Building rapport and demonstrating sensitivity

For this entire section, focus should be on appropriate communication/interaction with TGNC patient


• Showed respect for the patient


• Acknowledged and responded to patient's feelings and concerns


• Handled contextual/cultural factors ...

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