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Name: __________________________________ Evaluator: _______________________________

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Patient Interviewing Skills

Criteria

1. The student introduced him/herself.

YES = 0.5 points

NO = 0 points

2. The student verified the patient’s identity.

YES = 1 point

NO = 0 points

3. The student asked about past medical history.

YES = 1 point

NO = 0 points

4. The student asked about family and social history.

YES = 1 point

NO = 0 points

5. The student asked to list medications (Rx and OTC) and indications.

YES = 1 point

NO = 0 points

6. The student asked about medication adherence.

YES = 1 point

NO = 0 points

7. The student asked about allergies and reaction (if applicable).

YES = 1 point

NO = 0 point

8. The student had a closing statement.

YES = 0.5 points

NO = 0 points

9. The student asked ≤ 3 closed-ended questions.

YES = 1 point

NO = 0 points

10. The student used appropriate verbal communication (expressed empathy, used layperson’s terms, was clear and coherent, etc.).

YES = 1 point

NO = 0 points

11. The student used appropriate nonverbal communication (body language, eye contact, etc.).

YES = 1 point

NO = 0 points

Total Score: ______/10

Comments/Feedback:

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Patient Presentation Skills

Criteria

1. The student(s) presented the patient in the correct order (introduced patient, CC, PMH, pertinent FH/SH, medication history, allergies, pertinent labs, A/P).

YES = 1 point

NO = 0 points

2. The student(s) addressed:

YES = 1 point

NO = 0 points

3. The student(s) addressed:

YES = 1 point

NO = 0 points

4. The student(s) addressed:

YES = 1 point

NO = 0 points

5. The student(s) addressed:

YES = 1 point

NO = 0 points

6. The student(s) addressed:

YES = 1 point

NO = 0 points

7. The student(s) addressed:

YES = 1 point

NO = 0 points

8. The student(s) appropriately prioritized problems.

YES = 1 point

NO = 0 points

9. The student(s) recommended a treatment/withheld a treatment with a potential for HARM.

YES = –1 point

NO = 0 points

10. The student used appropriate verbal communication.

YES = 1 point

NO = 0 points

11. The student used appropriate nonverbal communication.

YES = 1 point

NO = 0 points

IESA Worksheet

Criteria

12. The student completed the IESA Worksheet

YES = 0 points

NO = –1 point

Total Score: ______/10

Comments/Feedback:

*Rubrics were created by faculty at Roseman University of Health Sciences.

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