CORD Standardized Direct Observational Assessment Tool

EM Outcomes Assessment

 

This assessment tool, the S-DOT, is designed to obtain objective data through observation of residents during actual ED patient encounters.  Each item should be judged as either: “Needs Improvement (NI),” “Meets Expectations (ME),” “Above Expected (AE),” or “Not Assessed (NA)” for level of training.

 



 

Resident's Name:                                Evaluated by: 

Date:                     PGY:   1  2  3

Time spent (minutes):                   Patient complaint:

# of patient encounters observed:

 

 

NI

ME

AE

N/A

Category

DATA GATHERING

 

 

 

 

 
  1. Respectful of patient’s privacy and confidentiality.

 

 

 

 

PC, PR
  1. Introduces self, appears professional, and efficiently establishes a respectful and effective communication with patient & family.

 

 

 

 

ICS, PR
  1. Uses language translation personnel when indicated.

 

 

 

 

ICS
  1. Gathers essential and accurate information from all available sources (i.e. patient, family, EMS, PMD, old records).

 

 

 

 

PC, SBP
  1. Performs a physical exam appropriate for the presenting complaint

 

 

 

 

PC

SYNTHESIS/ DDX

 

 

 

 

 
  1. Can explain the pathologic basis for management.

 

 

 

 

MK
  1. Presents the patient clearly and concisely.

 

 

 

 

MK, PC
  1. Explains an appropriate differential, plan, response, and disposition

 

 

 

 

 
  1. Understands indications and contraindications of a therapy or procedure.

 

 

 

 

MK

MANAGEMENT

 

 

 

 

 
  1. Sequences critical actions in patient care.

 

 

 

 

MK
  1. Competently performs a procedure, demonstrating knowledge of anatomy and observant of inherent risks.

 

 

 

 

MK, PC
  1. Communicates clearly, concisely, and professionally with staff

 

 

 

 

ICS, PR
  1. Anticipates, negotiates, and resolves conflicts effectively

 

 

 

 

IC,SP,PR
  1. Discusses the plan with the patient/family, updates them during their stay and acts as an advocate.

 

 

 

 

PR, SBP
  1. Clinical charting is timely, legible, and succinct, and reflects ED course and decision-making.

 

 

 

 

PC, PR
  1. Prioritizes patients appropriately by acuity and waiting time

 

 

 

 

SBP
  1. Plans patient work-up in view of possibilities and limitations of health care system (availability of tests, support systems, staffing)

 

 

 

 

SBP
  1. Plans patient work-up in view of patient’s social constraints (i.e. ability to pay, family support, work issues, etc.)

 

 

 

 

SBP
  1. Can handles distractions while maintaining patient care priorities

 

 

 

 

SBP
  1. Makes informed decisions about interventions using patient information and preferences, scientific evidence and clinical judgment

 

 

 

 

PC
  1. Reevaluates patient after diagnostic or therapeutic intervention

 

 

 

 

PC
  1. Documents reassessment and response to therapeutic intervention.

 

 

 

 

PC

DISPOSITION

 

 

 

 

 
  1. Uses resources such as social work and financial aid effectively

 

 

 

 

SBP
  1. Discharge and follow-up instructions verbalized to patient including appropriate anticipatory guidance.

 

 

 

 

PC, ICS
  1. Carries out appropriate discharge/admission/transfer plan, including notification of accepting MD or PMD as indicated

 

 

 

 

PC, SBP
  1. Arranges patient follow-up with an understanding of outpatient resources and the patient’s unique situation.

 

 

 

 

SBP

GLOBAL ASSESSMENT OF CORE COMPETENCIES

 


 

A.  Patient Care -that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health

Needs Improvement                         Meets Expectations                                      Above Expectation

1                                     2                              3                                4                                       5

Comments:

 

B.  Medical Knowledge - Residents are expected to formulate an appropriate differential diagnosis with special attention to life-threatening conditions, demonstrate the ability to utilize available medical resources effectively, and apply this knowledge to clinical decision making.

Needs Improvement                         Meets Expectations                                      Above Expectation

1                                     2                              3                                4                                       5

Comments:

 

C.  Practice-Based Learning and Improvement -that involves investigation and evaluation of their own patient care, appraisal and assimilation of scientific evidence, and improvements in patient care.

Needs Improvement                         Meets Expectations                                      Above Expectation

1                                     2                              3                                4                                       5

Comments:

 

D.  Interpersonal and Communication Skills -that result in effective information exchange and teaming with patients, their families, and other health professionals

Needs Improvement                         Meets Expectations                                      Above Expectation

1                                     2                              3                                4                                       5

Comments:

 

E.  Professionalism -as manifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population

Needs Improvement                         Meets Expectations                                      Above Expectation

1                                     2                              3                                4                                       5

Comments:

 

F.  Systems-Based Practice -as manifested by actions that demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value

Needs Improvement                         Meets Expectations                                      Above Expectation

1                                     2                              3                                4                                       5

Comments:

 

 

Circle best description of overall clinical competence for this patient encounter

 

Needs Improvement              Meets Expectations               Above Expectations    

 

Comments (Faculty or Resident):

 

 

 

 

                                                                                                                                                                       

Faculty Signature                              Date                                        Resident Signature                Date