Student Name: ______________________ Time of Session: ____________ Evaluator Name: ____________________

Answering Clinical Question from Health Care Provider Assessment Form

Answering Phone Points

Earned
Student identified him/herself and the pharmacy – 1 point
Student used appropriate title (e.g., Student Pharmacist) – 1 point
Total Points
Comments:

Gathering Information Points

Earned
Determined requestor’s name and profession – 2 points
Determined requestor’s contact information – 1 point
Determined deadline for response – 1 point
Obtained pertinent patient and/or other background information – 1 point each
 Patient demographics, if needed    
 Renal or hepatic function, if needed  
 Disease or condition, if needed  
 Medications and dosage, if needed  
 Other, as appropriate  
Exhibited appropriate and pleasant manner while gathering information – 3 points
Total Points
Comments:

Response Points
Earned
Student identified who he/she was and the reason for calling – 2 points
Student presented reasonable response to the question – 3 points
Student was able to provide appropriate resources to support the response – 3 points
Total Points
Comments:

Total Points
Total Number of “Yes” responses from above sections (out of __)

Global Assessment Positive Negative Neutral

Overall, the encounter left the following impression: