Neurology Clinical Evaluation

Transcription

1 Structured Assessment of Clinical Evaluation Report (STACER) Neurology Clinical Evaluation Procedure for the Conduct of the Clinical Examination The purpose of the STACER is to evaluate the neurology resident s ability to acquire a medical history from a patient or caregiver, perform a physical examination, interpret the acquired information and develop a management plan. The evaluator will also provide feedback to the resident. The STACER must be performed at a stage of training where the resident is acting as a junior consultant (PGY4 or PGY5). It can also be useful earlier in training. It is to be done during clinical care with a new patient referred to a Neurology service for consultation. The evaluating physician will select an appropriate patient who has been referred for consultation, obtain the patient s consent and ensure appropriate time and facilities are made available. During the first part of the STACER, the evaluating neurologist will observe the resident as the resident performs the history and physical examination. Organizing the STACER should not be onerous for the evaluating neurologist and it should be possible to incorporate it into usual clinical care with minor modifications. Other specific suggestions for the STACER are as follows: 1. The procedure for the STACER must be shown to the resident at least three days before the evaluation. 2. It is generally preferable to use different evaluators for each STACER, as this improves the effectiveness and validity of the experience and the assessment. In some cases, however, there may be advantages to using the same evaluator when repeating a STACER or a portion thereof. 3. The patient and caregiver (if applicable) will be brought to the examination room and introduced to the resident. The evaluator will review the process and then turn the encounter over to the resident. The evaluator should not ask questions or interrupt during the encounter unless there is a compelling reason to intervene (e.g., patient safety). 4. In Part I of the STACER, the resident will be allowed up to one hour for the interview and examination. The resident will then exit the interview room and may be given up to 15 minutes to reflect and organize his/her thoughts prior to Part II. During this interval, the evaluator may debrief the patient or caregiver, obtain additional history or examine the patient (in order to obtain relevant data that was missed or to confirm critical points in the clinical assessment) or discuss management. 5. Part II of the STACER consists of the resident presenting the history and physical findings, followed by a synthesis of the obtained data, a diagnostic formulation and a management plan. The evaluator may ask probing questions if necessary to clarify the resident s diagnostic and therapeutic reasoning. 6. The evaluator must observe and rate the resident s performance according to the evaluation grid. 7. At the end of the assessment, the evaluator must provide feedback on the resident s performance. 8. The resident must review and sign the assessment form. 9. A copy of the evaluation form will be sent to the Program Director. The resident must be able to successfully demonstrate the acquisition of the clinical skills as outlined in the STACER. Programs must assess the resident using the STACER (or portions thereof) as many times as are necessary to satisfy them that these skills have been acquired. The program must be able to attest that these competencies have been achieved by the end of training. Revised November 24, 2010 This document may be reproduced for educational purposes only provided that the following phrase is included in all related materials: Copyright 2011 The Royal College of Physicians and Surgeons of Canada. Referenced and produced with permission. Please forward a copy of the final product to the Office of Education, attn: Associate Director. Written permission from the Royal College is required for all other uses. For further information regarding intellectual property, please contact: documents@royalcollege.ca. For questions regarding the use of this document, please contact: credentials@royalcollege.ca.

2 Assessment Grid for Neurology Clinical Examination STACER - Part I History of Presenting Complaint(s) Elicits complete, relevant and accurate history. Pursues symptoms appropriately. Gains clear understanding of nature of illness. Comorbid Issues and Review of Systems Reviews and screens for relevant symptoms. Devotes appropriate time and attention to symptoms according to relevance. Past Medical History Reviews relevant past medical and surgical history and, when appropriate, gestational, perinatal and developmental history. Family History Reviews relevant family history. Medication History Reviews current medications. Social History Reviews family/marital status, education, occupation, smoking/ alcohol history, drug/toxin exposure, as appropriate. Communicator Avoids interrupting, uses open-ended questions appropriately. Refocuses patient and makes transitions effectively. Conducts complete/organized interview.

3 Physical Examination (see Examination Check-List) Examination Check-List Performs complete, organized, relevant examination, including language/cognitive function. Examines other organ systems when appropriate. Examination is organized. Comments Higher functions: speech, language cognition, including memory other cortical Cranial nerves (I XII) Motor (bulk, tone, strength, abn movements) Reflexes (tendon reflexes and other) Sensory (primary and cortical) Station, gait and coordination General examination (where indicated) Vital signs (BP, pulse, resp, temp) Spine and other joints Cardiovascular (including bruits) Skin, chest, abdomen, and genitalia Communicator/ Professional Introduces self, good rapport. Listens attentively. Displays empathy. Appropriate body language. Gives clear instructions during exam.

4 Assessment Grid for Neurology Clinical Examination STACER - Part II Presentation is lucid, succinct and organized. Case Presentation Presents clinical features and issues with appropriate weight. Presents appropriate and complete problem list. Localization Localizes lesion(s) appropriately using sound knowledge and reasoning. Differential Diagnosis Formulates appropriate differential diagnosis using sound knowledge and reasoning. Supports primary diagnosis with results of assessment and prior investigations. Plan of Investigation Identifies appropriate, cost-effective, ethically justifiable investigations. Treatment Plan Proposes organized, comprehensive and effective plan. Incorporates values and aspirations of patient and caregiver Properly assesses risks/benefits. Recommends safe treatments.

5 Resident Name Page 5 of 5 STACER - Overall Assessment of Resident Below Expectations Meets Expectations Summary of resident s strengths and weaknesses: Comments on the process: Date: Evaluator: Signature: Resident: Signature: