COLLEGE OF

OF PHYSICIANS AND DIRECT OBSERVATION OF PROCEDURAL SKILLS (DOPS)

SURGEONS PAKISTAN

Specialty: ___FCPS (IMM & Post-IMM) Prosthodontics_____

Time Duration = 20 mins (15 mins assessment and 5 mins feedback)
PLEASE COMPLETE THE QUESTIONNAIRE BY FILLING/CHECKING APPROPRIATE BOXES

Assessor: _____________________________________________Assessment Date:

________________________

Resident's Name:
_____________________________________________________________________________________

Hospital Name:_________________________________________R&RC Number:

__________________________

Year of Residency: □ R1 □ R2 □ R3 □ R4

Quarter: □ 1st □ 2nd □ 3rd □ 4th

Setting: □ O.T. □ Procedure Room Other:

Diagnosis of Patient:_____________________________________Patient Age:_________Sex:

_______________
Name of Procedure:
___________________________________________________________________________________
Complexity of Case/ Procedure: □ Low/Easy □ Moderate/Average □ High/Difficult □ N/A
Number of times procedure performed by Resident:
__________________________________________________________

Not Observed / Below Expectation Satisfactory Above Expectation Excellent

Please grade the following areas on the given scale: Applicable
1 2 3 4 5
Indications, anatomy & steps of procedure

Informed consent, with explanation of procedure and complications

Preparation for procedure

Use of Anesthesia, Analgesia or sedation

Observance of asepsis

Safe use of instruments/Materials

Use of accepted techniques

Management of unexpected event (or seeks help)

Post-procedure instructions to patient and staff

Professionalism

Overall ability to perform whole procedure

Assessor's Satisfaction with DOPS:

(Low) 1 2 3 4 5 (High)
Resident's Satisfaction with DOPS:
(Low) 1 2 3 4 5 (High)
 Strengths Suggestions for Improvements

Encounter to be repeated □ YES □ NO

Signature