A: Medical Knowledge
Trainee: ________________________________ Observer: ________________________________ Date: ______________
Training venue:
___ Family medicine RH clinic ___ Family medicine continuity clinic ___ High volume clinic: ______________________
|RESIDENT to complete/discuss: | |
|Number of PREVIOUS IUD insertion cases | |
|What is my learning goal for today? | |
|Overall RESIDENT impression of skill level |1 |
| |Beg |
| |2 |
| |Int |
| |3 |
| |Dev Comp |
| |4 |
| |Comp |
| |5 |
| |Adv Comp |
| | |
|What has been going well? | |
|What can be improved? | |
| | |
|FACULTY to complete: | |
|Number of observed resident cases today | |
|Overall FACULTY impression of skill level |1 |
| |Beg |
| |2 |
| |Int |
| |3 |
| |Dev Comp |
| |4 |
| |Comp |
| |5 |
| |Adv Comp |
| | |
|Were there any issues or problems? Did the trainer | |
|intervene at any time? | |
|What went well? | |
|What can be improved? | |
| | |
|Was this feedback discussed with the trainee? |_____ Yes _____ No |
|Interpersonal and Communication skills |N/A |1 |2 |3 |4 |5 |
| | |Beg |Int |Dev Comp |Comp |Adv Comp |
|Describes procedure using patient-centered language | | | | | | |
|Elicits, listens, and responds thoughtfully to patient’s questions and concerns | | | | | | |
|Communicates effectively with staff | | | | | | |
|Patient Care: I. IUD insertion – General |N/A |1 |2 |3 |4 |5 |
| | |Beg |Int |Dev Comp |Comp |Adv Comp |
|Discusses with patient what role (if any) a support person might play in this | | | | | | |
|process | | | | | | |
|Performs pregnancy test if needed | | | | | | |
|Uses supportive language to communicate to patient throughout the procedure | | | | | | |
|Accurately estimates uterine size and position from pelvic examination | | | | | | |
|Consistently uses no-touch technique | | | | | | |
|Inserts speculum gently for adequate visualization of the cervix | | | | | | |
|Endocervical GC/CT testing performed | | | | | | |
|Correct application of tenaculum | | | | | | |
|Demonstrates ability to sound uterus and identify appropriate depth for IUD | | | | | | |
|insertion | | | | | | |
|Inserts IUD/inserter through os with good traction on tenaculum | | | | | | |
|Cuts string to appropriate length | | | | | | |
|Reviews post-insertion instructions sheet with patient | | | | | | |
|Counsels patient regarding warning signs and when to contact the office for | | | | | | |
|follow up | | | | | | |
|II. Copper IUD |N/A |1 |2 |3 |4 |5 |
| | |Beg |Int |Dev Comp |Comp |Adv Comp |
|Sets flange to appropriate distance from tip | | | | | | |
|After insertion, withdraws insertion tube while holding stabilizing rod steady | | | | | | |
|thereby releasing IUD | | | | | | |
|Withdraws stabilizing rod and insertion tube from cervical canal | | | | | | |
|III. Liletta single-handed IUD |N/A |1 |2 |3 |4 |5 |
| | |Beg |Int |Dev Comp |Comp |Adv Comp |
|Pushes blue slider (1) away from self while pulling strings towards self so that | | | | | | |
|IUD arms load horizontally into insertion tube | | | | | | |
|Fixes threads into cleft | | | | | | |
|III. Liletta single-handed IUD (continued) |N/A |1 |2 |3 |4 |5 |
| | |Beg |Int |Dev Comp |Comp |Adv Comp |
|Advances handle until flange is 1.5–2 cm from external os | | | | | | |
|Slides blue slider (1) back gently until it is merged flush with the green slider| | | | | | |
|(2) while holding inserter steady and gives 15 seconds for arms to open | | | | | | |
|Advances IUD until flange are flush with cervix or IUD is at uterine fundus | | | | | | |
|Holds inserter in position and slides both sliders together all the way down | | | | | | |
|until it clicks. | | | | | | |
|Observes strings automatically releasing and if this does not happen, removes | | | | | | |
|them from cleft | | | | | | |
|Withdraws IUD inserter from uterus | | | | | | |
|IV. Levonorgestrel IUD (Bayer products) |N/A |1 |2 |3 |4 |5 |
| | |Beg |Int |Dev Comp |Comp |Adv Comp |
|Sets flange to appropriate distance from tip | | | | | | |
|Keeps thumb on blue slider while putting insertion tube through os | | | | | | |
|Advances handle until flange is 1.5–2 cm from external os | | | | | | |
|Pulls slider back to mid-mark while holding inserter steady and gives 10 seconds | | | | | | |
|for arms to open | | | | | | |
|Advances IUD until flange are flush with cervix or IUD is at uterine fundus | | | | | | |
|Holds inserter in position and moves slider all the way down | | | | | | |
|Withdraws IUD inserter from uterus | | | | | | |
|Knowledge |N/A |1 |2 |3 |4 |5 |
| | |Beg |Int |Dev Comp |Comp |Adv Comp |
|Can identify contraindications (CDC MEC) to both Copper T IUD and | | | | | | |
|Levonorgestrel-IUD | | | | | | |
|Can identify all needed supplies for the procedure | | | | | | |
|Can describe the correct order of steps of an IUD insertion | | | | | | |
|Can list criteria to be reasonably certain that a patient is not pregnant | | | | | | |
|Demonstrates knowledge of appropriate management of difficult insertions and/or | | | | | | |
|complications of IUD insertion | | | | | | |
Definitions
|N/A |Not Assessed | |MEDICAL KNOWLEDGE |INTERPERSONAL & PATIENT CARE |
|Beg |Beginner |Minimal experience |Possesses a limited understanding of relevant |Requires immediate supervision at all times and |
| | | |concepts and related protocols |specific hand-on-hand instruction to be able to |
| | | | |perform the stated task. |
|Int |Intermediate |Some prior experience |Has a fair understanding of relevant concepts |Requires close attention and frequent verbal |
| | | |and protocols. Asks appropriate questions |redirection to perform the stated task. |
|Dev Comp |Developing |Moderate prior |Has a strong understanding of relevant concepts|Requires intermittent supervision, but can perform the|
| |Competence |experience |and protocols. Knows limitations and seeks |stated task without detailed instruction. Recognizes |
| | | |guidance when needed |complications as they arise, but may not be able to |
| | | | |identify the associated management options |
|Comp |Competent |Significant prior |Has an extensive understanding of relevant |Competent for independent provision of this step. |
| | |experience |concepts and protocols |Infrequently requires assistance. Describes or |
| | | | |demonstrates comprehension of the management options |
| | | | |for atypical cases. |
|Adv Comp |Advanced Competency |Extensive prior |Able to teach others about relevant concepts |Competent for independent provision of this step AND |
| | |experience |and protocols |is able to teach this step to new learners. Able to |
| | | | |anticipate, recognize, and manage complications and |
| | | | |handle atypical or difficult cases; able to teach or |
| | | | |role model at a faculty level. |
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