PATIENT INTERVIEWING CONTENT AND SKILLS CHECKLIST

Please indicate if the student completed or elicited each of the following elements. You may prompt thestudent if s/he is missing critical elements of the interview.

 Ratings: done ( !   ), not done (0), not applicable (n/a)

History of Present Illness

 ____ Chief concern

 ____ Presenting symptoms, including SIGECAPS for patients presenting with depression:

S leep changes (insomnia or hypersomnia)I nterest (loss of)

G uilt or worthlessnessE nergy (low)

C oncentration (decreased)

A ppetite/weight (increased or decreased)

P sychomotor agitation or retardationS uicidal ideation

 ____ Psychiatric Review of Systems, including depression, mania, psychosis, anxiety

 ____ Recent self-injurious behavior

 ____ Recent aggressive behavior

 ____ Support system

 ____ Current stressors

Past Psychiatric History

 ____ Psychiatric diagnoses

 ____ Treatments, including medications, psychotherapy, ECT

 ____ Psychiatric hospitalizations

 ____ Suicide attempts, including context and consequences

Family History

 ____ Family history of psychiatric disorders

 ____ Family history of completed suicide

Social History

 ____ Family of origin

 ____ Adverse events during childhood, including abuse, trauma and loss

 ____ Educational background, including years of education

 ____ Military history

 ____ Relationship status, including partner and children

 ____ Living situation (including housing)

 ____ Employment status

 ____ Cultural or spiritual beliefs

 ____ Legal issues, including history of violence/aggression

 

 

Habits

 ____ Current use of tobacco, and interest in quitting

 ____ Current and past use of alcohol, including history of alcohol withdrawal

 ____ Current and past use of marijuana and other illicit drugs

 ____ Misuse of prescription medications

Mental Status Exam (during interview)

 ____ Mood

 ____ Suicidal ideation, including intent, plan and means

 ____ Homicidal ideation

 ____ Hallucinations, specifically auditory and visual

 ____ Delusions

 ____ Orientation

 ____ SLUMS (if there is evidence of cognitive impairment)

Interview Skills

 ____ Uses patient’s name at introduction

 ____ Uses open-ended questions

 ____ Does not interrupt patient

 ____ Uses plain, non-medical language

 ____ Asks patient to clarify unclear information

 ____ Uses transitional statements

 ____ Obtains permission to discuss sensitive topics

 ____ Avoids multiple simultaneous questions

 ____ Interview conducted with sensitivity to patient’s emotional state

Evaluation of Interview

 ____ Meets expectations: student covered the majority of elements listed above

 ____ Does not meet expectations: student missed many elements

Comments regarding Interview

 

PRESENTATION AND WRITE UP CHECKLIST

Please indicate if the student presented each of the following elements.

 Ratings: done ( !   ), not done (0), not applicable (n/a)

Elements of

Mental Status Exam

Presented orally

after interview

Accurately recorded

in write-up

Appearance ___ ___

Behavior ___ ___Speech ___ ___

Mood ___ ___Affect ___ ___

Thought Processes ___ ___Thought Content

- suicidal ideation ___ ___- homicidal ideation ___ ___

- hallucinations ___ ___- delusions ___ ___

Cognition

-alertness/arousal ___ ___-orientation ___ ___

-SLUMS, if confusion ___ ___or memory impairment

Insight & judgment ___ ___

Evaluation of MSE presentation and write up

 ___ Meets expectations: student covered the majority of elements listed above

 ___ Does not meet expectations: student missed many elements

Comments regarding presentation and write up

 

OVERALL EVALUATION

Professionalism -  Ratings: acceptable ( !   ), deficient (0)  ___ Respect for others: attentive during group activities 

 ___ Response to feedback: accepts and enacts feedback ___ Accountability: punctual and prepared

 ___ Appearance: professional and appropriate appearance ___ Initiative: Committed to improvement, participates without being asked

 ___ Timeliness of assignments: completes write up within one week of interview

Evaluation of Professionalism

 ___ Meets expectations: all of the above are checked

 ___ Does not meet expectations: one or more elements missing

Overall evaluation for Patient Interviewing small group, including interview, presentation,

write up and professionalism

 ___ Pass: meets expectations for interview AND meets expectations for presentation and write-up AND meets expectations for professionalism

 ___ Fail: does not meet expectations for interview OR does not meet expectations for

 presentation and write-up OR does not meet expectations for professionalism