MINICEX CONFIDENTIAL EVALUATION FORM 1 Step 1 MINI CEX PERFORMANCE FORM DOCTOR NAMEyour full nameaccount_circle EVALUATOR+ TODAYS DATEyour full nameaccount_circle PATIENT PROBLEM OR CHIEF COMPLAINTyour full nameaccount_circle INTRODUCTION/CLOSURE COMPLETED?HIGH PERFORMANCEADEQUATEINADEQUATE/SOMEWHATPOOR PATIENTNEW FOLLOWUP HOW CAN THIS BE IMPROVED? PLEASE SPECIFY EXAMPLESmore details0 / COMPLEXITY OF CASELOWMEDIUMHIGH FOCUSDATA GATHERINGDIAGNOSIS THERAPYCOUNSELING MEDICAL INTERVIEWING SKILLSNOT OBSERVED-0UNSATISFACTORY-1UNSATISFACTORY-2UNSATISFACTORY-3SATISFACTORY-4SATISFACTORY-5SATISFACTORY-6SUPERIOR-7SUPERIOR-8SUPERIOR-9 PHYSICAL EXAMINATION SKILLSNOT OBSERVED-0UNSATISFACTORY-1UNSATISFACTORY-2UNSATISFACTORY-3SATISFACTORY-4SATISFACTORY-5SATISFACTORY-6SUPERIOR-7SUPERIOR-8SUPERIOR-9 HUMANISTIC QUALITIES/PROFESSIONALISMNOT OBSERVED-0UNSATISFACTORY-1UNSATISFACTORY-2UNSATISFACTORY-3SATISFACTORY-4SATISFACTORY-5SATISFACTORY-6SUPERIOR-7SUPERIOR-8SUPERIOR-9 CLINICAL JUDGEMENTNOT OBSERVED-0UNSATISFACTORY-1UNSATISFACTORY-2UNSATISFACTORY-3SATISFACTORY-4SATISFACTORY-5SATISFACTORY-6SUPERIOR-7SUPERIOR-8SUPERIOR-9 COUNSELING SKILLSNOT OBSERVED-0UNSATISFACTORY-1UNSATISFACTORY-2UNSATISFACTORY-3SATISFACTORY-4SATISFACTORY-5SATISFACTORY-6SUPERIOR-7SUPERIOR-8SUPERIOR-9 ORGANIZATION-EFFICIENCYNOT OBSERVED-0UNSATISFACTORY-1UNSATISFACTORY-2UNSATISFACTORY-3SATISFACTORY-4SATISFACTORY-5SATISFACTORY-6SUPERIOR-7SUPERIOR-8SUPERIOR-9 OVERALL CLINICAL COMPETENCENOT OBSERVED-0UNSATISFACTORY-1UNSATISFACTORY-2UNSATISFACTORY-3SATISFACTORY-4SATISFACTORY-5SATISFACTORY-6SUPERIOR-7SUPERIOR-8SUPERIOR-9 EMPATHY/BEDSIDE MANNER/COUNSELING COMPLETED?HIGH PERFORMANCEADEQUATEINADEQUATE/SOMEWHATPOOR HOW CAN THIS BE IMPROVED? PLEASE SPECIFY EXAMPLESmore details0 / EYE CONTACT MADE? PROFESSIONALISM DISPLAYED THROUGHOUT ENCOUNTER?HIGH PERFORMANCEADEQUATEINADEQUATE/SOMEWHATPOOR HOW CAN THIS BE IMPROVED? PLEASE SPECIFY EXAMPLESmore details0 / HISTORICAL QUESTIONS COMPLETED? ANY MISSING?PERFECTMOSTLY COMPLETEINADEQUATEPOOR WHAT HISTORICAL QUESTIONS WERE MISSING? PLEASE PROVIDE SPECIFIC EXAMPLESmore details0 / PHYSICAL EXAM COMPLETED? PLEASE SPECIFY WHICH STEPS WERE MISSED.PERFECTMOSTLY COMPLETEINADEQUATEPOOR HOW CAN THIS BE IMPROVED? PLEASE SPECIFY EXAMPLESmore details0 / SPOKEN ENGLISH CLEAR? UNDERSTANDABLE? WHAT WORDS WERE MISPRONOUNCED?PERFECTMOSTLY CLEARINADEQUATEPOOR HOW CAN THIS BE IMPROVED? PLEASE SPECIFY EXAMPLESmore details0 / MEDICAL TERMINOLOGY USED?GIVE EXAMPLES? DID DOCTOR MAKE IT EASY AND USE LAYMENS TERMS?PERFECTADEQUATEINADEQUATE/SOMEWHATPOOR HOW CAN THIS BE IMPROVED? PLEASE SPECIFY EXAMPLESmore details0 / DIFFERENTIALS CORRECT? WHAT DID DOCTOR GIVE AS IMPRESSION? IF INCORRECT TYPE OUT WHAT IT SHOULD HAVE BEEN, IF NONE GIVEN TYPE "INCOMPLETE" THEN TYPE OUT WHAT IT SHOULD HAVE BEEN.PERFECTDDX CLOSE W/ SLIGHT MISDIAGNOSISMISSED DIAGNOSISNONE GIVEN DIFFERENTIAL DIAGNOSIS 1. IF INCORRECT TYPE CORRECT DIAGNOSIS DIFFERENTIAL DIAGNOSIS 2 IF INCORRECT TYPE CORRECT DIAGNOSISmore details0 / DIAGNOSTIC STUDIES/ TESTS GIVEN? IF INCOMPLETE TYPE "INCOMPLETE"PERFECTSOME CORRECT, SOME INCORRECTINADEQUATENONE GIVEN DIAGNOSTIC STUDY 1 IF INCORRECT TYPE CORRECT TEST. DIAGNOSTIC STUDY 2 IF INCORRECT TYPE CORRECT TESTmore details0 / WAS ENCOUNTER FINISHED ON TIME? WAS ENCOUNTER ACCEPTABLE? WHAT IS DOCTORS MAIN WEAKNESS?FINISHED EARLYRIGHT ON TIMEJUST BARELY RAN OUTNOT EVEN CLOSE PLEASE PROVIDE SUGGESTIONS, AND GIVE AN OVERALL STATEMENT ON DOCTORS MAIN WEAKNESS.more details0 / SANITIZED HANDS BEFORE ENCOUNTER BEFORE PHYSICAL AND BEFORE LEAVING?SANITIZED 3xSANITIZED 2xSANITIZED 1xNONE USEDNOT APPLICABLE ADDITIONAL COMMENTS OR SUGGESTIONS FOR THIS DOCTOR?more details0 / OVERALL PERFORMANCEHIGH PASSPASSBORDERLINEFAILEPIC FAIL Submit keyboard_arrow_leftPrevious Nextkeyboard_arrow_right
