EPA 1B: Perform a Clinical Examination
SCOPE OF WORK: This activity includes examining and documentating clinical and radiographic findings of extraoral and intraoral soft and hard tissues, TMJ, occlusion, periodontium, dentition, and restorations.
Domains of Competence
- Person-Centered Care
- Critical Thinking and Decision Making
- Biomedical Science Application
Knowledge
- Infection control
- Components of clinical examination
- Examination armamentaria and techniques
- Normal vs abnormal clinical and radiographic findings including but not limited to TMD
- Signs of clinical pathology
- Strategies for ensuring patient behavior guidance, comfort, and cooperation in performing clinical examination
- Required documentation specific to clinical examination in electronic patient record (Epic Wisdom -charting, progress note, etc.)
Skills
- Perform examination in person-centered manner in compliance with infection control
- Utilize strategies, including behavior guidance, to maximize patient comfort and cooperation
- Examine the patient accurately and comprehensively including but not limited to TMD
- Apply appropriate examination techniques and procedures informed by an understanding of disease processes
- Apply critical thinking skills to distinguish relevant information
- Apply critical thinking skills to differentiate normal from abnormal, and when and how to explore further
- Document proper elements components of patient history in electronic patient record (Epic Wisdom)
| Perform a Clinical Examination |
Meets Expectations of the Graduate
|
Progressing
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Below Expectations
|
Critical Error
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|---|---|---|---|---|
| Performance of Clinical Exam |
Technically performs each required component1 of the exam correctly and, systematically.
|
Knows the required components1 to be performed and technically performs most of the components correctly | Omits required components1 of the exam or incorrectly performs many of the components | Omits or incorrectly performs most of the critical components 1 of the exam |
| Differentiation of Normal and Abnormal Findings | Correctly differentiates normal from abnormal findings including but not limited to TMD | Correctly differentiates normal from abnormal for most findings, needing guidance on those most difficult to differentiate | Fails to differentiate normal from abnormal for many findings or ones easy to differentiate | Fails to differentiate an abnormal finding that can result in patient harm |
1 Refer to Appendix B: Diagnosis and Treatment Planning Presentation Template
Rating on "Documentation" for this encounter will be included for the assessment of this task.