Ea ACO LOL Wot Yet Please assess and mark the BOG following domains es Competent | Professional | NIA } ) Preparation & Professional ‘approach (including communication, flow and knowledge ‘of the detail ofthe case without having to ‘constantly look for info.) Pertinent History (Chief complaint, history, past medical history, psychosocial, and family history) ‘Differential Diagnosis (Min, 2_Ddx’s ~ In detail (Inc. Duration, soverity, ‘sie, ocation, tissue and pathology, not too Pertinent Physical Examination {Clear concise pertinent examination findings, ‘should follow flow of the examination and ‘support Ddx's & Dx’s) Diagnosis (Clear precise Dx (Inc. Duration, severity, side, Tocation, tissue and pathology) ‘Treatment plan includi interventions (Clear outline of step by step interventions from ‘point of presentation to ideal end point of addressing patient goals, should inc. passive ‘and active progressions) ‘Prognosis including barriers to recovery (Must use one of Excellent, Good, Fair, Guarded ‘of Poor, detailing barriers and support) itcome Measui (Named PROMS & tag tests listed inc. details as ‘to how they will be deployed in terms of time frame for reassessments and how they will be ‘used for treatment progression) ther im Further investigations and/or ‘onward Referral (if relevant) Re further “Treatment plan should be supported by research with evidence of further reading of BAlS Scanned with CamScanner‘Tomments: Suggestions for development (assessor comments): Should be a clear flow from the information presented through History, examination, Ddx’s to Dx and treatment plan? ‘Must be supported by research with evidence of further reading around the cas L vow ayo Very Aeev t Ge [lew Gud jew appninds ‘Umpire Kony yop ie GUAMUAW~ ASS - 1 suDleer's Self-reflection (to be completed by the intern) — what did you learn from this experience, what would you do differently next time. What steps can you implement to ensure the time you perform this procedure you will do it more professionally: = Ao adder) cheaper ere) Cjrert a) auNte preven She, to Stancl oct ole — pracktiona + precex the paar hour viper plvoctes( ‘Agreed Action (Intern and Assessor initial): @ Page 2 of 2 al Scanned with CamScanner