Trainee: _________________________

Evaluator: ______________________

Date: _________
Indicate the rating that best describes the clinician’s performance:
Beginner: Close observation / monitoring and supervision; Demonstrates limited fund of knowledge or significant gaps.
Developing Competence: Developing independent thinking and needs intermittent assistance/supervision; knows limitations and seeks guidance when needed; Demonstrates improving fund of knowledge with some gaps.
Competent: Independent; need for assistance and direct supervision is occasional; knows limitations and seeks guidance when needed; asks appropriate questions to attending; approaches task of supervision of peers; demonstrates solid fund of knowledge with rare gaps.


Beginner Developing Competence Competent
A: Patient Care
Reviews history thoroughly; asks additional questions as indicated
Confirms patient consent
Accurately estimates uterine size and position from pelvic examination
Able to interpret sonogram findings for dating and completion of abortion
Asks and answers questions in a patient-centered manner (one that is free of personal judgments and is focused on meeting the patient’s expressed needs)
Discusses post abortion contraceptive options and prescribes as necessary
ASPIRATION for Abortion or EPL
Administers analgesics/sedatives in appropriate doses
Provides effective paracervical block
Safely dilates cervix to correct size for gestational age
Consistently uses no-touch technique      
Communicates with patient during the procedure with attention to her comfort and expectations
Safely assimilates landmarks for uterine aspiration (flexion, fibroids, etc.)
Accurately assesses when uterus is empty
Maintains adequate speed performing procedure
Examines POCs for appropriate elements and consistency with gestational age
Prescribes appropriate post-procedure medications as needed
Provides anticipatory guidance for post-procedure course
Effectively manages difficulties encountered during procedure (ex. dilation, cervical laceration, anatomical variations)
MEDICATION for Abortion or EPL
Prescribes and administers medications according to protocol
Appropriately counsels patient about procedure taking into account life circumstances
Provides patient centered counseling
Provides anticipatory guidance to distinguish expected side effects from complications
Appropriately assess for completion of abortion
Demonstrates appropriate management of complications of medication abortion
B: Communication and Interpersonal Skills
Consistently introduces him/herself to patients
Consistently uses open-ended questions when counseling patients
Establishes rapport with the patient
Provides patient-centered options-counseling
C. Professionalism
Arrives at clinic on time
Demonstrates respect for patients and staff
Maintains strict patient confidentiality
Is receptive to constructive feedback
Documents all relevant patient data
Is aware of his/her limitations
D. Systems-Based Practice
Able to compare and contrast the delivery of reproductive services provided in family practice setting with that in family planning clinic system
Demonstrates knowledge of range of access issues related to abortion services including billing and insurance
E. Practice-Based Learning and Improvement
Assimilates feedback from evaluation to improve patient care practices
Demonstrates ability to appraise and assimilate evidence from scientific studies to support patient care decisions
F. Medical Knowledge
Describes the differences between medication and aspiration abortion
Identifies factors pertinent to abortion care during patient history review
Describes the expected process of an uterine aspiration
Describes the expected process of a medication abortion
Identifies contraindications to medication abortion
Knows appropriate use of medications
Knows appropriate use and interpretation of laboratory tests
Identifies features of ectopic pregnancy
Knows contraceptive options and contraindications to specific methods
Knows indications for sonography


SIGNATURE OF EVALUATOR: ____________________________________ DATE: ____________


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