Inpt Service Assessment

	Yes	No	N/A
Reviewed chart prior to entering room
Displayed knowledge of patient's history, including tests/procedures done during current stay
Addressed anxiety about medication changes
Took responsibility for coordinating with PCP/ Consultants

Provider Communication

	Yes	No	N/A
SMALL TALK-Made small talk at beginning
INTRO-Introduced themselves beyond their name
INTRO-Gave patient business card
INTRO-Explained role
BODY-Consistent eye contact
BODY-Sat leaning forward toward patient when not examining
BODY-Leaned onto bed rail when standing
BODY-Arms not crossed
BODY-Smiled as appropriate
VOICE-Appropriate tone
STANDARD QUESTIONS-Let patient know that they will be asking a series of questions
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-Walked patient through diagnosis/prognosis/procedure in 'journey-like' manner
EXPLAINING-Used whiteboard to visualize
EXPLAINING-Avoided complex jargon
EXPLAINING-Questions were answered to patient's satisfaction
EXPLAINING-Explained discharge process and expected time
EMPATHY-Displayed Empathy
PACE-Visit did not appear rushed

Improvement Plan
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:

	Yes	No	N/A
Managed Up Resident
Explained role of Resident
Introduced Med Student
Did not cast doubt or pass blame on other caregivers or processes