This Communication Observation Form is also available in Word format (16 KB).
Please observe the interaction between a patient and a clinician. After the encounter, rate whether you agree, are neutral, or disagree with the statements in the table. Feel free to write notes that can help the clinician improve their communication in the future.
| Question | Agree | Neutral | Disagree |
|---|---|---|---|
| 1. For patients or companions whose preferred language is not English: This clinician used qualified interpreters or spoke to them fluently in their preferred language. | |||
| 2. This clinician greeted the patient warmly and maintained a caring attitude. | |||
| 3. This clinician was respectful and made appropriate eye contact. | |||
| 4. This clinician used open-ended questions to encourage the patient and companions to participate in the conversation and voice their concerns throughout the visit. | |||
| 5. This clinician listened without interrupting. | |||
|
6. This clinician covered no more than 1 to 3 key points and reviewed them more than once. |
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| 7. This clinician used plain, nonmedical language. | |||
| 8. This clinician spoke clearly and at a moderate pace. | |||
| 9. This clinician gave specific, concrete explanations and instructions. | |||
| 10. This clinician used graphics such as a picture, diagram, or model to help explain something (if applicable). | |||
| 11. This clinician demonstrated how to do something (e.g., how to take medicine or exercise) (if applicable). | |||
| 12. This clinician created the expectation that they wanted the patient and companions to ask questions (e.g., asking 鈥淲hat questions do you have?鈥). | |||
| 13. This clinician checked that they were clear by asking the patient to describe what they need to know or do using their own words or by demonstrating. |
Please provide other feedback about the encounter below:
