FORMULIR MINI-CEX

(Mini Clinical Examination)

UNTUK UJIAN KOMPETENSI KLINIK (Ujian Ruangan)
IPDSA FK UNAIR / RSUD dr. SOETOMO SURABAYA

Name of Supervisor : _______________ Date of Examination : 19 January - 28 February 2021

Name of Resident : dr. Radhitio Adi Nugroho Level : Junior / Madya / Senior
Diagnosis of patient _____________________________________________________
Patient : Age : ___________ Gender: _______  New patient  Follow-up
Level of Difficulty :  Low  Medium  THigh

SCORE < 50 50-59 60-69 70-79 80-100

E D C B A

1. Medical Interviewing Skills

2. Physical Examination Skills

3. Humanistic Qualities/Professionalism

4. Clinical Judgment/ Diagnosis

5. Management Skills

6. Counseling Skills

7. Organization/Efficiency

8. Overall Clinical Competence

Score
ANNOTATION
86 - 100 A 62 - <70 BC <40 E
78 - <86 AB 54 - <62 C
70 - <78 B 40 - <54 D NBL: 70 Mean Score

FEED BACK:

Good already Need improvement

Mutually agreed action:

NOTES:
1. Duration of case discussion: observation: ____ minute, Feed back ____minute
2. Supervisor satisfaction with the case discussion:
a. Very low b. Low c. Enough d. Good e. Very good
3. Resident’s satisfaction with the case discussion:
a. Very low b. Low c. Enough d. Good e. Very good
4. Have you ever received training to use this evaluation tool?

Joint training Face to face Reading the guideline WEB/ CD dll

Sign,

( __________________________ )
 FORMULIR CbD
(CASE-BASED DISCUSSION)
UNTUK UJIAN KOMPETENSI KLINIK (Ujian Ruangan)
IPDSA FK UNAIR / RSUD dr. SOETOMO
SURABAYA

Name of Supervisor : ______________________ Date of Examination : 19 January - 28 February 2021

Name of Resident : dr. Radhitio Adi Nugroho Level : Junior / Madya / Senior

Room situation : □ ER □ Outpatient □ Inpatient □ Others

Patient’s diagnosis : ___________________________________________________________

Focus : □ Medical record □ Clinical assessment □ Management

□ Professionalism
Level of Difficulty : □ Low □ Medium □ High
SCORE < 50 50-59 60-69 70-79 80-100
E D C B A

1. Medical record’s writing

( ) Not observed
2. Clinical assessment
( ) Not observed
3. Iinvestigation and Referral
( ) Not observed
4. Management
( ) Not observed
5. Follow up and future planning
( ) Not observed
6. Professionalism
( ) Not observed
7. Clinical assessment in general
( ) Not observed

ANNOTATION Total score

86 - 100 A 62 - <70 BC <40 E
78 - <86 AB 54 - <62 C
70 - <78 B 40 - <54 D NBL: 70
Mean score

FEED BACK:

Good already Need improvement

Mutually agreed action:

NOTES:
1. Duration of CbD: observation: ____ minute, Feed back ____minute
2. Supervisor satisfaction with the CbD:
a. Very low b. Low c. Enough d. Good e. Very good
3. Resident’s satisfaction with the CbD:
a. Very low b. Low c. Enough d. Good e. Very good
4. Have you ever received training to use this evaluation tool?

Joint training Face to face Reading the guideline WEB/ CD dll

Sign,

( __________________________ )
 FORMULIR DOPS
(DIRECT OBSERVATION OF PROCEDURAL SKILL)
UNTUK UJIAN KOMPETENSI KLINIK (Ujian Ruangan)
IPDSA FK UNAIR / RSUD dr. SOETOMO SURABAYA

Name of Supervisor : _________________ Date of Examination : 19 January - 28 February 2021

Name of Resident : dr. Radhitio Adi Nugroho Level : Junior / Madya / Senior
Room situation : ER Outpatient Inpatient Others
Jenis Tindak medik : _________________________________________________________
No.of similar medical actions were observed by the supervisor: ( ) 0 ( ) 1 ( ) 2 ( ) 3 ( ) 4 ( ) 5-9 ( ) >9
No. of similar medicat action were done by the resident : ( ) 0 ( ) 1 ( ) 2 ( ) 3 ( ) 4 ( ) 5-9 ( ) >9

SCORE < 50 50-59 60-69 70-79 80-100

E D C B A

1. Have knowledge of indications,

the relevance of anatomic and
follow-up medical techniques
( ) Not observed

2. Get informed consent

( ) Not observed

3. Able to show preparation adequately

before medical procedur
( ) Not observed

4. Able to give safe analgetic/sedation

( ) Not observed

5. Technical skill
( ) Not observed

6. Aseptic technique
( ) Not observed

7. Ask for help if needed

( ) Not observed

8. Management post procedure

( ) Not observed

9. Communication skill
( ) Not observed

10. Professionalism
( ) Not observed

11. Skill to do medical procedure in general

( ) Not observed

ANNOTATION Total score

86 - 100 A 62 - <70 BC <40 E
78 - <86 AB 54 - <62 C
70 - <78 B 40 - <54 D NBL: 70 Mean score

FEED BACK:

NOTES:
1. Duration of DOPS: observation: ____ minute, Feed back ____minute
2. Supervisor satisfaction with DOPS:
a. Very low b. Low c. Enough d. Good e. Very good
3. Resident’s satisfaction with DOPS:
a. Very low b. Low c. Enough d. Good e. Very good
4. Have you ever received training to use this evaluation tool?

Joint training Face to face Reading the guideline WEB/ CD dll

Sign,

( __________________________ )