COMPETENCY SIGN-OFF (OBSERVED PERFORMANCE EVALUATION)
Trainee: Evaluator: Date:
Using the rubric below, please indicate the rating that best describes the clinician’s performance:
- Not Applicable (NA) or Not Observed
- Beginner (B): Limited fund of knowledge; requires constant assistance and supervision.
- Advanced Beginner (AB): Developing independent thinking. Requires intermittent observation/assistance. Knows limitations and seeks guidance when needed.
- Developing Competence (DC): Developing independent thinking. Needs intermittent assistance/ supervision; knows limitations, seeks guidance when needed;
- Competent (C): Assistance or supervision is occasional. Knows limitations and seeks guidance when needed. Asks appropriate questions to advance understanding and technique.
- Advanced Competence (AC): No observation required. Assistance or consultation is rare. Knows limitations and seeks guidance when needed. Discusses complex cases with attending. Can supervise and teach others when applicable
| Communication and Interpersonal Skills | 0 (N/A) |
1 (B) |
2 (AB) |
3 (DC) |
4 (C) |
5 (AC) |
| Introduces themselves and states their role | ||||||
| Uses open-ended questions; answers patient questions | ||||||
| Establishes rapport, and demonstrates compassion | ||||||
| Uses respectful / gender inclusive language, free from medical jargon | ||||||
| Communicates in patient-centered and trauma-informed manner | ||||||
| Systems-Based Practice | ||||||
| Able to discuss impact of reproductive health restrictions and burden on disparities | ||||||
| Practice-Based Learning and Improvement | ||||||
| Responds to in-the-moment tips/ feedback | ||||||
| Ask questions about evidence and assimilates evidence readily into patient care | ||||||
| Medical Knowledge | ||||||
| Identifies factors pertinent to care and risk during history review | ||||||
| Knows appropriate pain mgmt for pts using opioids or buprenorphine | ||||||
| Identifies contraindications to medication & aspiration abortion | ||||||
| Knows appropriate use and interpretation of laboratory tests | ||||||
| Identifies risks and describes work-up of ectopic pregnancy | ||||||
| Knows indications for sonography | ||||||
| Patient Care | ||||||
| Describe process & risks to consent for procedures & care | ||||||
| Counsels accurately on contraceptives & contraindications | ||||||
| Correctly places IUD or implant | ||||||
| Ultrasound | ||||||
| Able to interpret US findings for dating & completion of abortion | ||||||
| Knows and assesses for FEEDS criteria in early pregnancy | ||||||
| Reliably finds cervix on TAUS and TVUS | ||||||
| 0 (N/A) |
1 (B) |
2 (AB) |
3 (DC) |
4 (C) |
5 (AC) |
|
| ASPIRATION for Abortion or EPL | ||||||
| Accurately estimates uterine size and position | ||||||
| Places appropriately sized speculum w/ minimal handling or discomfort | ||||||
| Administers analgesics/sedatives in appropriate doses | ||||||
| Provides paracervical block safely | ||||||
| Safely dilates cervix to correct size for gestational age | ||||||
| Consistently uses “no-touch” technique | ||||||
| Correctly chooses dilator & cannula size | ||||||
| Safely identifies uterine landmarks (internal os, flexion, etc.) | ||||||
| Quickly loads and reloads MVA | ||||||
| Accurately appreciates when uterus is empty | ||||||
| Able to complete uncomplicated procedure in < 10 minutes | ||||||
| Calls for / uses TAUS guidance as appropriate | ||||||
| Examines POCs for appropriate elements; consistency with GA | ||||||
| Provides anticipatory guidance for post-procedure course | ||||||
| Effectively manages anatomic challenges encountered during procedure (ex. dilation, anatomical variations) | ||||||
| Lists causes and steps in management of hemorrhage | ||||||
| Lists steps in management of vasovagal | ||||||
| Lists steps in management of perforation | ||||||
| MEDICATION for Abortion or EPL | ||||||
| Accurately counsels patient throughout the process | ||||||
| Describes routine side effects vs. warning signs | ||||||
| Explains appropriate alternatives for follow-up | ||||||
| Prescribes and administers medications according to protocol | ||||||
| Appropriately assesses for completion of abortion | ||||||
| Demonstrates approp. mgmt of post-MAB bleeding | ||||||
ADDITIONAL COMMENTS:
SIGNATURE OF EVALUATOR: ___________________________
DATE: _______________