Trainee:                                         Evaluator:                                         Date:                             

Using the rubric below, please indicate the rating that best describes the clinician’s performance:

  1. Not Applicable (NA) or Not Observed
  2. Beginner (B):  Limited fund of knowledge; requires constant assistance and supervision.
  3. Advanced Beginner (AB): Developing independent thinking. Requires intermittent observation/assistance. Knows limitations and seeks guidance when needed.
  4. Developing  Competence (DC):  Developing independent thinking. Needs intermittent assistance/ supervision; knows limitations, seeks guidance when needed;
  5. Competent (C):  Assistance or supervision is occasional. Knows limitations and seeks guidance when needed. Asks appropriate questions to advance understanding and technique.
  6. 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
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
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
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


SIGNATURE OF EVALUATOR: ___________________________

DATE: _______________


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