Feedback

Simulated patient feedback form for students

This form could be used to give feedback to students and gives a few tips and pointers for comments.  Ideally this template could be used if there were mutiple students or sessions and it might be hard to recall student performances.

COMMUNICATIONS CHECKLIST

 During the simulation I felt that the student:

 Made a personal connection during the visit (e.g., went beyond medical issues at hand, conversed about personal background, interests, job, etc.).    YES NO
Gave me an opportunity/time to talk (e.g., didn't interrupt). YES NO
Listened. Gave me undivided attention (e.g., eye contact, verbal acknowledgment, non-verbal feedback).        YES NO
Checked/clarified information (e.g., recapped, paraphrased, echoed, summarised, asked for clarification when not certain about what I described).         YES NO
Encouraged me to ask questions/checked my understanding of information provided.         YES NO
Adapted to my level of understanding, using appropriate language (e.g., avoided or explained jargon; avoided child-like slang).   YES NO
Expressed empathy (e.g., demonstrated care and concern for me, acknowledged my feelings, expressed understanding of my feelings/ respect for my situation/ willingness to support me).    YES NO
Maintained a respectful tone (e.g., did not belittle me; did not use humour inappropriately, did not talk down to me).     YES NO
Involved me in deciding upon a plan (e.g., presented me with options [if any], provided rationale for their assessment).      YES NO
Elicited and addressed any concerns I have about the plan.               YES NO

Did you ever feel uncomfortable during the course of the encounter?

If yes, please comment. Please describe when this occurred, what specific behaviour led to this feeling, and how you felt

 

YES NO

Did the student ever appear uncomfortable during the course of the encounter?

If yes, please comment. Please describe when this occurred, what specific behaviour led to this feeling, and how you felt

 

YES NO

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