Clinic Service Assessment

Resident/ APP

Rows	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

Rows	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

Med Hx/ PC

Rows	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

Rows	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

Pt Appeared satisfied at end of visit
How would pt rate provider in your opinion

1 2 3 4 5 6 7 8 9 10
1 is Worst, 10 is Best
Tip 1
Tip 2
Tip 3
Should be Empty:

Rows	Yes	No	N/A
MA escorted patient from lobby
MA managed up process
MA gave time expectations
MA answered questions appropriately