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Please observe the interaction between a patient and a specific clinician or staff member. Answer the following questions either yes or no to provide feedback about the quality of the communication you observe. Feel free to write notes that can help the clinician or staff member to improve his or her communication in the future.
| 1. Did this clinician or staff member explain things in a way that was easy to understand? | Yes | No |
| 2. Did this clinician or staff member use medical jargon? | Yes | No |
| 3. Was this clinician or staff member warm and friendly? | Yes | No |
| 4. Did this clinician or staff member interrupt when the patient was talking? | Yes | No |
| 5. Did this clinician or staff member encourage the patient to ask questions? | Yes | No |
| 6. Did this clinician or staff member answer all the patient’s questions? | Yes | No |
| 7. Did this clinician or staff member see the patient for a specific illness or for any health condition? | Yes | No |
| If No, Form Is Complete | ||
| a. Did this clinician or staff members give the patient instructions about what to do to take care of this illness or health condition? | Yes | No |
| If No, Form Is Complete | ||
| b. Were these instructions easy to understand? | Yes | No |
| c. Did this clinician or staff member ask the patient to describe how they were going to follow these instructions? | Yes | No |
Please note any other comments about the encounter below:
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