Clinic Service Assessment

Clinic Service Assessment

Validation of service excellence for physicians in an ambulatory setting. Form Preview
  • Clinic Service Assessment

    • Provider Info  
    • Patient Information  
    • Rooming Process  
    •   Yes No N/A
      MA escorted patient from lobby
      MA managed up process
      MA gave time expectations
      MA answered questions appropriately
    • Resident/ APP  
    •   Yes No N/A
      Resident/APP informed patient at beginning that they will see scheduled physician
      Resident/APP avoided duplicative questions
      Resident/APP displayed empathy
      Resident/APP appeared aware of Med Hx
    • Provider Communication  
    •   Yes No N/A
      SMALL TALK-Made small talk at beginning
      INTRO-Introduced themselves beyond their name
      BODY-Consistent eye contact
      BODY-Sat leaning forward toward patient when not examining
      BODY-Arms not crossed
      BODY-Appropriate use of smiling
      VOICE-Appropriate tone
      STANDARD QUESTIONS-Let patient know that they will be asking a series of questions
      STANDARD QUESTIONS-Made patient aware of duration of questioning
      VISUAL QUEUES-Noticed when patient not comprehending and reworded
      VISUAL QUEUES-Stopped to ask for questions when discussion became complex
      LISTENING-Did not interrupt patient
      LISTENING-Asked what questions patient had (Open ended)
      LISTENING-Nodded head while patient speaking
      LISTENING-Allowed silence before responding to patient
      EXPLAINING-Managed up AVS to reduce anxiety
      EXPLAINING-Walked patient through diagnosis/prognosis/procedure in 'journey-like' manner
      EXPLAINING-Used visual to explain
      EXPLAINING-Avoided complex jargon
      EMPATHY-Displayed Empathy
      PACE-Visit did not appear rushed
    • Medical History/ Computer  
    •   Yes No N/A
      Made pt aware that they are using EMR during visit
      Reviewed records prior to visit
      Made mention of reviewing the records prior to visit
      Turned monitor to face pt
      Went through medical history with patient
      Asked patient for any additional/missing info
    • Managing Up  
    •   Yes No N/A
      Informed pt of workflow in academic medicine and its value
      Managed up Resident
      Managed up APP regarding followup visits
      Managed up consultant when making referral
      Did not pass blame on any person/process during pt experience
    • Durations  
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    • Improvement Plan  
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    • Should be Empty: