MINI CEX PERFORMANCE FORM

EVALUATOR+ TODAYS DATEyour full name

INTRODUCTION/CLOSURE COMPLETED?

HIGH PERFORMANCEADEQUATEINADEQUATE/SOMEWHATPOOR

HOW CAN THIS BE IMPROVED? PLEASE SPECIFY EXAMPLESmore details

0 /

FOCUS

DATA GATHERINGDIAGNOSIS THERAPYCOUNSELING

EMPATHY/BEDSIDE MANNER/COUNSELING COMPLETED?

HIGH PERFORMANCEADEQUATEINADEQUATE/SOMEWHATPOOR

EYE CONTACT MADE? PROFESSIONALISM DISPLAYED THROUGHOUT ENCOUNTER?

HIGH PERFORMANCEADEQUATEINADEQUATE/SOMEWHATPOOR

HISTORICAL QUESTIONS COMPLETED? ANY MISSING?

PERFECTMOSTLY COMPLETEINADEQUATEPOOR

PHYSICAL EXAM COMPLETED? PLEASE SPECIFY WHICH STEPS WERE MISSED.

PERFECTMOSTLY COMPLETEINADEQUATEPOOR

SPOKEN ENGLISH CLEAR? UNDERSTANDABLE? WHAT WORDS WERE MISPRONOUNCED?

PERFECTMOSTLY CLEARINADEQUATEPOOR

MEDICAL TERMINOLOGY USED?GIVE EXAMPLES? DID DOCTOR MAKE IT EASY AND USE LAYMENS TERMS?

PERFECTADEQUATEINADEQUATE/SOMEWHATPOOR

DIFFERENTIALS 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 GIVEN

DIAGNOSTIC STUDIES/ TESTS GIVEN? IF INCOMPLETE TYPE "INCOMPLETE"

PERFECTSOME CORRECT, SOME INCORRECTINADEQUATENONE GIVEN

WAS ENCOUNTER FINISHED ON TIME? WAS ENCOUNTER ACCEPTABLE? WHAT IS DOCTORS MAIN WEAKNESS?

FINISHED EARLYRIGHT ON TIMEJUST BARELY RAN OUTNOT EVEN CLOSE

MINICEX CONFIDENTIAL EVALUATION FORM