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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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