PCP OBE-CBTP RTP-ACC Form #7 2019

PCP OBE-CBTP IN INTERNAL MEDICINE

ASSESSMENT TOOL FOR DIRECT OBSERVATION OF PROCEDURAL SKILLS (DOPS)
TASIM 04125121
ALEXANDER
HI Date:_________
Name of Resident: ___________________________Year Level:______
Formative Evaluation Summative Evaluation

I. There are two (2) categories of procedural skills that the medical residents have to acquire and be assessed.
a. Mandatory skills (must be able to do competently without assist with a score of ‘satisfactory’):
i. NGT insertion
ii. Foley catheter insertion
iii. Technique for getting ECG tracing
iv. Arterial puncture for ABG
v. Abdominal paracentesis
vi. Thoracentesis
vii. Endotracheal intubation
viii. Setting up of Mechanical ventilator

b. Desirable skills (has 2 levels of competencies: able to do competently with or without assist with a score of
‘satisfactory’):
i. Central venous line insertion
ii. Joint aspiration
iii. Thyroid gland aspiration / FNAB
iv. Bone marrow aspiration
v. Pleurodesis
vi. Proctosigmoidoscopy
vii. Gram stain
viii. AFB smear
ix. Lumbar tap
x. Urinalysis (microscopic interpretation of sediments)

II. Four-step approach to teaching procedures:

• This approach allows residents to learn both the cognitive and psychomotor steps in performing a procedure.
• The teacher must explain the resident’s and teacher’s role in performing the procedure.
• An informed consent must be obtained from the patient.

a. First step: Break down the procedure into its component parts:
i. Indications and contraindications for the procedure.
ii. Necessary equipment / instruments / consumables.
iii. Proper preparation and positioning of the patient.
iv. Individual steps of the actual procedure.

b. Second step: The teacher demonstrates the procedure to the resident slowly – talking through each step.

c. Third step: The teacher performs the procedure, but the resident will talk through each part of the procedure.

d. Fourth step: The resident actually perform the procedure, talking through each step that he is taking.

An Introduction to Medical Teaching by Janet M. Riddle

III. The resident can only undertake the summative assessment after undergoing the four-step
approach to teaching procedures (as describe above).
IV. It is preferable that summative assessment for all the procedural skills be done early during the
training, preferably YL I and II.
V. Only one (1) summative assessment with a score of 7 or better is recorded in the Workplace
Performance Assessment tool. The four-step approach to teaching procedures will serve as the
formative assessment.

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Instruction: Assess the resident for each of the steps for DOPS utilizing the rating scale below. Provide
ample feedback. No step must be missed. MPL for each step is 5-7 or ‘satisfactory’. If for any reason a step
is missed, then the assessment must be repeated.
1 2 3 4 5 6 7 8 9 10
UNSATISFACTORY SATISFACTORY EXCELLENT

A. General assessment for DOPS (applicable for all the procedural skills).
Score
NGT FOLEY ECG ABG Abdominal Thora- Endotracheal Mech
CATH paracentesis centesis Intubation Vent
1. Conduct yourself in a
professional and appropriate
manner.
99 9 a 9
2. State the indications and
9g
Type text here
contraindications of the
procedure.
q q q
3. Explain procedure to
patient and ‘immediate
responsible person’ including 9
benefits and risks; get 99 9 9
consent; ensure patient’s
privacy.
4. Prepare all necessary
equipment / instruments /
consumables including 99 8 9
9
containers for specimen and
waste disposals.
5. Observe aseptic technique;
prepare and position the 99 8 8 9
patient.
6. Follow each step and 8
proper sequence of the
procedure. (see below).
89 8 q
7. Show dexterity and ease
during the procedure. 89 7 7 7
8. Able to perform the

89
procedure without causing
undue discomfort or 7 79
complications to the patient.
9. Show proper handling of
specimens and waste 99 8 8 9
material
10. Give adequate advice to
the patient on post-procedure
care and instruction on 99 9 99
possible complications.

Signature of assessor / date

Feedback

B. Steps and proper sequence for each procedure:

1) Nasogastric tube insertion Score Feedback

1. List and prepare all necessary equipment / instruments / consumables

including containers for specimen and waste disposals. a
2. Place patient in a supine position with head slightly flex at 30-45 0 . a
3. Estimate the length of the tube to be inserted. Do this by measuring the
nasogastric tube from the tip of the nose to the earlobe and then to a
the xiphisternum.

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4. Lubricate the tip of the nasogastric tube. 9
5. Insert the NGT through either nostril – warn the patient prior to insertion. 9
6. Gently advance the NGT through the nasopharynx. Ask the patient to
swallow while inserting the tube. DO NOT force the NGT. If the patient is
becoming distressed or gagging, pause to allow the patient to relax. 7
Continue to advance the NGT down the esophagus.
7. Check the desired placement of the NGT by insufflating air through the tube
using asepto-syringe. Detect for gastric bubbling.
9
8. Secure NGT placement using a plaster. 9

Signature of Assessor / Date

2) Foley catheter insertion Score Feedback

1. List and prepare all necessary equipment / instruments / consumables

including containers for specimen and waste disposals.
9
2. Position patient properly:
2.1 Female catheterization: The female urethra is short compared to the male
urethra. It is located above the vagina in the pelvis. Ask the patient lie down on
his or her back with the buttocks at the edge of the examination table. Elevate
:
and support the legs by stirrups or placing them in a frog-legged position for
adequate exposure of the urethra. Finally, separate the labia to expose the
urethra.
2.2 Male catheterization: The male urethra is long compared to the female 9
urethra. Ask the patient to lie down or do the frog-legged position. Retract the
foreskin to its maximal level if present.
3. Clean the urethra and the surrounding areas with cotton-ball dipped in
antiseptic solution. Beginning at the urethra, the cleansing is performed in a 9
circular motion, moving outward to the surrounding areas.
4. Insert the lubricated Foley catheter into the bladder through the urethra. a
5. Inflate the balloon slowly once the catheter is passed through the bladder 9
with 10 cc water in a syringe. Inflating the balloon should not be painful.
6. Observe for the flow of urine through the catheter and into the sterile
drainage bag.
9
7. Withdraw the catheter gently from the urethra until resistance is met. 9
8. Secure the catheter to the patient’s thigh with a wide tape. Creating a gutter
to elevate the catheter from the thigh may increase the patient’s comfort.
9
Signature of Assessor / Date

3) Technique for getting ECG tracing Score Feedback

1. List and prepare all necessary equipment / instruments / consumables: hand

sanitizer, ECG machine, 10 sticky pads for attaching the electrodes, wipes / wet
cotton, razor (optional).
2. Identify the patient for ECG; Ask patient to lie down
3. Prepare skin appropriately for the procedure.
4. Position the electrodes correctly: (Chest and Limb leads)
Limb Leads: RL – Anywhere above the right ankle and below the torso
RA – Anywhere between the right shoulder and the wrist
LL – Anywhere above the left ankle and below the torso
LA – Anywhere between the left shoulder and the wrist
Chest Leads : V1 – Fourth intercostal space at the right sternal border
V2 – Fourth intercostal space at the left sternal border
V3 – Halfway between leads V2 and V4
V4 – Fifth intercostal space in the midclavicular line
V5 – Left anterior axillary line on the same horizontal
plane as V4
V6 – Left midaxillary line on the same horizontal plane
as V4 and V5

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5. Record the ECG according to standard guidelines.
6. Review the quality of the tracings and respond appropriately.

Signature of Assessor / Date

4) Arterial puncture for ABG Score Feedback

1. List and prepare all necessary equipment / instruments / consumables

including containers for specimen and waste disposals: sterile/ Non- sterile
gloves, antiseptic skin solution; heparinized 3ml ABG syringe with a gauge 22-
25 gauge needle and syringe cap; 2x2 sterile gauze; adhesive bandage, plastic 9
hazard bag, sharp object container; Lidocaine (if the patient requests it)
2. Select appropriate site: Radial artery, brachial artery, femoral artery, dorsalis
pedis. 9
3. Palpate the artery with one or two fingers while holding the needle in the
other hand. 8
4. Puncture the artery with the needle at 30-45 0 angle and draws
approximately 2-3 ml of bright red blood. 7-
5. Remove the needle and immediate apply pressure to the area thereafter. 8
6. Ensure hemostasis. Apply longer duration of pressure for at least 5 minutes if

%
necessary.
7. Discard hazardous wastes.
8. Monitor for post procedure complications such as discoloration, pain,
bleeding and loss of movement of the affected limb.

Signature of Assessor / Date

5) Abdominal paracentesis Score Feedback

1. List and prepare all necessary equipment / instruments / consumables

including containers for specimen and waste disposals.
2. Asks patient to empty the bladder and position the patient. Midline and lateral
approaches can be used for paracentesis, with the left-lateral technique more
commonly employed. The left-lateral approach avoids air-filled bowel that
usually floats in the ascitic fluid. The patient is placed in the supine position and
slightly rotated to the side of the procedure to further minimize the risk of
perforation during paracentesis. Because the cecum is relatively fixed on the
right side, the left-lateral approach is most commonly used.
3. Prepare the skin with povidone iodine or chlorhexidine solution and allow it to
dry.
4. Administer anesthesia: 1% Lidocaine.
5. Insert the needle usually 2-3 cm below the umbilicus.
6. Aspirate fluid as you advance the needle
7. Remove the introducer needle; attach the stopcock and connect the tubing to
the 1L bottle.
8. Collect fluid and send to laboratory for analysis.
9. Secure needle in place while draining fluid.
10. After draining fluid, gently remove catheter and apply pressure to the
wound.
11. Ask the patient to lie down flat on bed and monitor vital signs for four hours.

Signature of Assessor / Date

6) Thoracentesis Score Feedback

1. List and prepare all necessary equipment / instruments / consumables

including containers for specimen and waste disposals.
2. Place patient in sitting position with arms and head supported on a bedside
adjustable table.
3. Confirm extent of pleural effusion by chest percussion; chest x-ray and/or
ultrasound.

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4. Select thoracentesis site in an interspace below the point of dullness to
percussion in the mid-posterior line or mid-axillary line.
5. Mark insertion point and prepare area with skin cleansing agent.
6. Administer local anesthetic agent (lidocaine 1%) over insertion point. Insert
needle over the top of the rib to avoid intercostals nerves and blood vessels. As
the needle is inserted aspirate back on syringe to check for pleural fluid. Once
fluid returns, note depth of the needle to give approximate depth for insertion of
thoracentesis needle.
7. Switch to a large bore needle (g16-19) and attach to a 3-way stopcock and
place a 30-50 ml syringe on one port of the stopcock.
8. Insert the needle along the upper border of the rib while aspirating and
advance it into the effusion.
9. Insert the catheter (or plastic cover) over the needle into the pleural space
when fluid is aspirated, and withdraw the needle, leaving the catheter (or plastic
cover) in the pleural space. While preparing to insert the catheter, cover the
needle opening during inspiration to prevent entry of air into the pleural space.
10. Withdraw fluid for testing and place in appropriate bottles.
11 Monitor patient’s symptoms and VS. Stop if with chest pain, dyspnea , cough
and hypotension. Do not drain more than 1500 ml.
12. Remove catheter while patient is holding breath.
13. Apply sterile dressing to insertion site.
14. Give post thoracentesis instructions.

Signature of Assessor / Date

7) Endotracheal intubation Score Feedback

1. List and prepare all necessary equipment / instruments / consumables

including containers for specimen and waste disposals.
2. Check equipment and check endotracheal cuff for leaks. %
3. Insert stylet into endotracheal tube. 9
4. Attach blade to battery base and assess light function. Have back-up blades
of different type and sizes available. 7-
5. Preoxygenate with 100% O2 using ambu-bag.
6. If necessary administer appropriate sedatives or opioids.
%
a
7. Have an assistant apply cricoid pressure.
8. Assess for ability to mask ventilate. 9
9. If appropriate administer appropriate neuromuscular blockade and assess for 9
clinical effect.
10. Grasp the laryngoscope in the left hand. 9
11. Open the patient’s mouth with the cross-finger technique. 7-
12. Insert slowly the blade into the right side of the patient’s mouth using it to
push the tongue to the left. Advance the blade inward and midline toward the 7-
base of the tongue.
13. Place the tip of the curved blade in front of the epiglottis in the valecula.
Place the tip of the straight blade under the epiglottis. Apply pressure caudally 7
and upward with the handle at a 450 angle to the bed.
14. Lift the handle until the vocal cords are visualized ensuring that the blade or 7
handle is not levered against the incisors.
15. Grasp the ETT tube with stylet inserted in the right hand. 9
16. Insert gently the ETT along the right side of the mouth under direct 7-
visualization of the vocal cords until the cuff is no longer visible.
17. Hold firmly the ETT in place, withdraw the blade, remove the stylet, and 8
inflate the ETT cuff with 5-10ml of air.
18. Assess for proper placement of ETT by end tidal CO2 waveform, fogging in
ETT, bilateral breath sounds, symmetric chest movement, and absence of 9
breath sounds over the epigastrium, as well as return to baseline vital signs.
19. Deflate the cuff and remove the ETT if assessment indicates that the ETT is
not placed in the trachea. Resume mask ventilation with 100% O2. Consult with 8
ICU fellow or anesthesia staff on strategy to re-attempt intubation.
20. Deflate the cuff and withdraw the ETT 1-2cm and evaluate for correct
placement if breath sounds are absent on the left. Palpate the suprasternal 7
notch feeling for the ETT cuff.

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21. Attach and secure the ETT with tape or appropriate device. 9
22. Attach the ETT to the mechanical ventilator. 9
23. Order and review ‘stat’ portable chest x-ray to evaluate the location of the 9
tip of the ETT.
24. Order and review arterial blood gas 30 minutes post intubation. 9
Signature of Assessor:

8) Setting of Mechanical Ventilator (volume-controlled) Score Feedback

1. List and prepare all necessary equipment / instruments / consumables

including containers for specimen and waste disposals. 9
2. Check patient’s level of consciousness. 9
3. Check patient’s spontaneous respiratory rate and breathing pattern. 9
4. Check patient’s breath sounds.
5. Note endotracheal or tracheostomy tube size and position and ensure
patency.
6. Determine mode of ventilation.
%
7. Set tidal volume.
8. Set ventilator frequency or back-up rate. &
9. Set peak flow rate (if ventilator does not have option to set peak flow rate,
determine the I:E ratio). 9
10. Set FiO2. 9
11. Set PEEP. 9
12. Hook patient to the mechanical ventilator (attach ventilator tubing to the ET 9
or tracheostomy).
13. Check if adequate tidal volume is delivered. 7
14. Check peak airway pressures if acceptable. 7-
15. Set pressure support level (if applicable). a
16. Set waveform (if applicable). 7
17. Set sensitivity threshold (if applicable). 7
18. Activation of high pressure and low pressure alarms (volume, pressure,
rate). 7
19. Check for any patient-ventilator asynchrony. 7
20. Get arterial blood gas 30 minutes to 1 hour after hooking to the mechanical
ventilator. 9
21. Interpret the arterial blood gas and compute for the desired oxygenation.
22. Adjust tidal volume, back-up rate, FiO2 and PEEP based on arterial blood
gas post-hooking to MV.
&
Signature of Assessor: