COT Assessment for Trainers

Clinician Specialty: General Practitioner Information Gathering Encourages the patient's contribution: Excellent Justification for the assessment of how the clinician encouraged patient contribution, including specific examples of what was said or done: Dr. Sharma actively listened, made eye contact, and frequently asked open-ended questions like, "How has this been affecting your daily life?" and "What are your main concerns today?". She also invited the patient to share additional thoughts at the end of the history taking. Responds to cues: Competent Justification for the assessment of the clinician's response to cues, including specific examples of verbal or non-verbal cues and the clinician's reaction: The patient visibly winced when describing lower back pain, and Dr. Sharma immediately followed up with, "It looks like that's quite uncomfortable for you. Can you tell me more about that specific feeling?" This demonstrated good awareness and responsiveness. Places complaint in appropriate psychosocial contexts: Excellent Justification for the assessment of how the clinician placed the complaint in context, including specific examples of psychosocial factors explored: Dr. Sharma inquired about the patient's living situation, work stress, and recent family bereavement, linking these potential stressors to the patient's reported symptoms of anxiety and sleep disturbance. She asked, "Given the recent loss of your mother, how do you feel this stress might be impacting your current symptoms?" Explores patient's health understanding/beliefs including identifying and addressing patients ideas and concerns and expectations: Excellent Defines the clinical problem Takes an appropriately thorough and focused history to allow a safe assessment (includes/excludes likely relevant significant condition): Excellent Performs appropriate physical or mental state examination: Competent Makes an appropriate working diagnosis: Competent Explains the problem to the patient Explains the problem in appropriate language: Excellent Addresses the patients' problem The management plan (including any prescription) is appropriate for the working diagnosis: Excellent Patient is given the opportunity to be involved in significant management decisions: Excellent The doctor checks that there is shared understanding of the diagnosis, management plan, treatment, safety netting and follow up arrangements: Excellent Makes effective use of the consultation Makes effective use of available resources: Competent The doctor specifies the conditions and interval for follow up or review: Competent