FORM

Mini CEX
No. FK/FORM/ADM-AKD/19/Rev-00 Tanggal Berlaku : 1 Februari 2018

Assessor ___________________ Student. _____________________ Date _____________

Patient Problem/Dx(s) _____________________________________ Age ___ Gender ___

Setting ___________ PROBLEM COMPLEXITY: ___ Low ___ Moderate ___ High

1. MEDICAL INTERVIEWING SKILLS ( Not Observed)

1 2 3 | 4 5 6 | 7 8 9

Unsatisfactory Satisfactory Superior

2. PHYSICAL EXAMINATION SKILLS ( Not Observed)

1 2 3 | 4 5 6 | 7 8 9

Unsatisfactory Satisfactory Superior

3. PROFESSIONALISM/ HUMANISTIC QUALITIES

1 2 3 | 4 5 6 | 7 8 9

Unsatisfactory Satisfactory Superior

4. COUNSELLING SKILLS

1 2 3 | 4 5 6 | 7 8 9

Unsatisfactory Satisfactory Superior

5. CLINICAL JUDGMENT ( Not Observed)

1 2 3 | 4 5 6 | 7 8 9

Unsatisfactory Satisfactory Superior

6. ORGANIZATION/EFFICIENCY

1 2 3 | 4 5 6 | 7 8 9

Unsatisfactory Satisfactory Superior

OVERALL CLINICAL COMPETENCE

1 2 3 | 4 5 6 | 7 8 9

Unsatisfactory Satisfactory Superior

Mini-CEX time Observing ___ min. Providing feedback ___ min.

Comments on Student’s Performance (Describe what was effective and ineffective, and your overall impression)

Assessor Signature