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Student Name ___________________________ Evaluator Name __________________________

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  Confident and Consistent Needs Development Needs Significant Development


  • 1. Introduced self (name and position)

  • 2. Greeted patient

  • 3. Established patient’s identity using a secondary identifier

  • 4. Obtained patient’s concerns

  • 5. Described purpose of encounter


Establish patient-provider relationship

  • 6. Showed respect for patient

  • 7. Acknowledged and responded to patient’s feelings and concerns


Verbal communication skills

  • 8. Gave the patient time and opportunity to talk

  • 9. Used open-ended and nonleading questions

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

  • 11. Avoided filler words (um, uh, like)


Nonverbal communication skills

  • 12. Made appropriate eye contact

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


Managing the encounter

  • 14. Conducted the encounter in a logical format

  • 15. Managed time effectively


Concluding the encounter

  • 16. Verified patient understanding (teach-back)

  • 17. Gave the patient opportunity for questions

  • 18. Expressed thanks to patient and explained what would happen next


Feedback for students (provide one strength and one area for improvement):

Comments to instructors (document any incorrect information provided by student or additional information):

*Adapted from: Kimberlin CL. Communicating with patients: skills assessment in US colleges of pharmacy. Am J Pharm Educ. 2006;70(3):67. doi:10.5688/aj700367

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