ICU Workplace-Based Assessment Form - PROCEDURES Initiated # ICU months: Name of Trainee: (Months of ICU rotation completed since ☐ assessment: beginning of CCM program) Initiated Name of Faculty: MM / DD / YY Date: ☐ assessment: ☐ ☐ ☐ ☐ Setting: ICU E.R. Ward Post-Op Unit ☐ ☐ ☐ ☐ Procedure: Intubation CVC insertion tube Bronchoscopy Complexity: ☐ ☐ ☐ Low Moderate High Low-risk, non-urgent routine Some elements of anatomical Complex and atypical anatomy, procedure with normal anatomy. challenges, urgency, and/or emergency, and/or very high-risk circumstances. circumstances. Brief case description: CHOOSE 2 AREAS OF FEEDBACK. For each, provide: 1) narrative comments on trainee's strengths, areas for development, and improvement strategies, and 2) choose a level of autonomy on the entrustment scale. NEEDS NEEDS NEEDS MINIMAL AUTONOMOUS EXPERT INTERVENTIONS DIRECTIONS GUIDANCE Able to do without Able to do in complex Unable to do without Partially able to do with Mostly able to do with guidance; refinement situations; personal others’ actions. others’ directions. minimal guidance. possible with feedback. insight on performance. Areas of feedback Feedback Narrative Comments ☐ Knowledge of indications, anatomy, and technique Ability to understand and explain the indications, risks, anatomy, and technique of a procedure. INTERVENTION DIRECTION GUIDANCE AUTONOMOUS EXPERT ☐ ☐ ☐ ☐ ☐ Narrative Comments ☐ Consent/Communication Ability to provide clear and understandable information to patient/family and to encourage questions. INTERVENTION DIRECTION GUIDANCE AUTONOMOUS EXPERT ☐ ☐ ☐ ☐ ☐ Narrative Comments ☐ Preparation/Analgesia & Sedation Ability to prepare site and material, to position the patient, to anticipate complications, and to provide appropriate INTERVENTION DIRECTION GUIDANCE AUTONOMOUS EXPERT analgesia/sedation. ☐ ☐ ☐ ☐ ☐ Narrative Comments ☐ Technical Ability Manual dexterity, correct procedural sequence, and minimal hesitation or unnecessary actions. INTERVENTION DIRECTION GUIDANCE AUTONOMOUS EXPERT ☐ ☐ ☐ ☐ ☐ Narrative Comments
ICU Workplace-Based Assessment Form - PROCEDURES Name of Trainee: Initiated assessment: ☐ # ICU months: (Months of ICU rotation completed since beginning of CCM program) Name of Faculty: Initiated assessment: ☐ Date: MM / DD / YY Setting: ☐ ICU ☐ E.R. ☐ Ward ☐ Post-Op Unit Procedure: ☐ Intubation ☐ CVC insertion ☐ tube ☐ Bronchoscopy Complexity: ☐ Low Low-risk, non-urgent routine procedure with normal anatomy. ☐ Moderate Some elements of anatomical challenges, urgency, and/or circumstances. ☐ High Complex and atypical anatomy, emergency, and/or very high-risk circumstances. Brief case description: CHOOSE 2 AREAS OF FEEDBACK. For each, provide: 1) narrative comments on trainee's strengths, areas for development, and improvement strategies, and 2) choose a level of autonomy on the entrustment scale. NEEDS INTERVENTIONS Unable to do without others’ actions. NEEDS DIRECTIONS Partially able to do with others’ directions. NEEDS MINIMAL GUIDANCE Mostly able to do with minimal guidance. AUTONOMOUS Able to do without guidance; refinement possible with feedback. EXPERT Able to do in complex situations; personal insight on performance. Areas of feedback Feedback ☐ Knowledge of indications, anatomy, and technique Ability to understand and explain the indications, risks, anatomy, and technique of a procedure. Narrative Comments INTERVENTION ☐ DIRECTION ☐ GUIDANCE ☐ AUTONOMOUS ☐ EXPERT ☐ ☐ Consent/Communication Ability to provide clear and understandable information to patient/family and to encourage questions. Narrative Comments INTERVENTION ☐ DIRECTION ☐ GUIDANCE ☐ AUTONOMOUS ☐ EXPERT ☐ ☐ Preparation/Analgesia & Sedation Ability to prepare site and material, to position the patient, to anticipate complications, and to provide appropriate analgesia/sedation. Narrative Comments INTERVENTION ☐ DIRECTION ☐ GUIDANCE ☐ AUTONOMOUS ☐ EXPERT ☐ ☐ Technical Ability Manual dexterity, correct procedural sequence, and minimal hesitation or unnecessary actions. Narrative Comments INTERVENTION ☐ DIRECTION ☐ GUIDANCE ☐ AUTONOMOUS ☐ EXPERT ☐ Narrative Comments
Assessment+Forms_PROCEDURE_July+2017.docx