GOLD CS MSPE MSPEPlease enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Doctor Number # *DOORWAY CASE PROBLEM/ REASON FOR VISIT *INTRODUCTION/CLOSURE COMPLETED? *HIGH PERFORMANCEADEQUATEINADEQUATE/SOMEWHATPOORHOW CAN THIS BE IMPROVED? PLEASE SPECIFY EXAMPLESEMPATHY/BEDSIDE MANNER/COUNSELING COMPLETED? *HIGH PERFORMANCEADEQUATEINADEQUATE/SOMEWHATPOORHOW CAN THIS BE IMPROVED? PLEASE SPECIFY EXAMPLESEYE CONTACT MADE? PROFESSIONALISM DISPLAYED THROUGHOUT ENCOUNTER? *HIGH PERFORMANCEADEQUATEINADEQUATE/SOMEWHATPOORHOW CAN THIS BE IMPROVED? PLEASE SPECIFY EXAMPLESHISTORICAL QUESTIONS COMPLETED? ANY MISSING? *PERFECTMOSTLY COMPLETEINADEQUATEPOORWHAT HISTORICAL QUESTIONS WERE MISSING? PLEASE PROVIDE SPECIFIC EXAMPLESPHYSICAL EXAM COMPLETED? PLEASE SPECIFY WHICH STEPS WERE MISSED.HIGH PERFORMANCEADEQUATEINADEQUATEPOORHOW CAN THIS BE IMPROVED? PLEASE SPECIFY EXAMPLESSPOKEN ENGLISH CLEAR? UNDERSTANDABLE? WHAT WORDS WERE MISPRONOUNCED? *PERFECTADEQUATEINADEQUATE/SOMEWHATPOORHOW CAN THIS BE IMPROVED? PLEASE SPECIFY EXAMPLESMEDICAL TERMINOLOGY USED?GIVE EXAMPLES? DID DOCTOR MAKE IT EASY AND USE LAYMENS TERMS? *PERFECTADEQUATEINADEQUATE/SOMEWHATPOORHOW CAN THIS BE IMPROVED? PLEASE SPECIFY EXAMPLESDIFFERENTIALS CORRECT? WHAT DID DOCTOR GIVE AS IMPRESSION? IF INCORRECT TYPE OUT WHAT IT SHOULD HAVE BEEN, IF NONE GIVEN TYPE "INCOMPLETE" THEN TYPE OUT WHAT IT SHOULD HAVE BEEN. *PERFECTDDX CLOSE W/ SLIGHT MISDIAGNOSISMISSED DIAGNOSISNONE GIVENDIFFERENTIAL DIAGNOSIS 1. IF INCORRECT TYPE CORRECT DIAGNOSIS DIFFERENTIAL DIAGNOSIS 2 IF INCORRECT TYPE CORRECT DIAGNOSISDIAGNOSTIC STUDIES/ TESTS GIVEN? IF INCOMPLETE TYPE "INCOMPLETE" *HIGH PERFORMANCEPERFECTSOME CORRECT, SOME INCORRECTINADEQUATENONE GIVENDIAGNOSTIC STUDY 1 IF INCORRECT TYPE CORRECT TEST. DIAGNOSTIC STUDY 2 IF INCORRECT TYPE CORRECT TESTWAS ENCOUNTER FINISHED ON TIME? WAS ENCOUNTER ACCEPTABLE? WHAT IS DOCTORS MAIN WEAKNESS? *FINISHED EARLYRIGHT ON TIMEJUST BARELY RAN OUTNOT EVEN CLOSEPLEASE PROVIDE SUGGESTIONS, AND GIVE AN OVERALL STATEMENT ON DOCTORS MAIN WEAKNESS.SANITIZED HANDS BEFORE ENCOUNTER BEFORE PHYSICAL AND BEFORE LEAVING? *SANITIZED 3xSANITIZED 2xSANITIZED 1xNONE USEDNOT APPLICABLEADDITIONAL COMMENTS OR SUGGESTIONS FOR THIS DOCTOR?OVERALL PERFORMANCE *HIGH PASSPASSBORDERLINEFAILEPIC FAILSubmit
