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- Foundations STACER Assessment Form(PGY2 practice and FOD STACERs)
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Procedures and Guidelines
- COD STACER Procedures - July 2017
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- Guidelines for Site-based Implementation of Structured Assessment of Clinical Evaluation Reports (STACERs)
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Please don't hesitate to contact us at psych.stacer@utoronto.ca. if you have any questions or concerns.
Differences between FOD and COD STACER Exams
1. Interview Process
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|
Foundations |
Core |
Item |
Expectation |
Criterion |
Criterion |
Rapport |
Establishes relationship |
Introduces self Explains interview Respectful Open, explorative beginning |
Introduces self Explains interview Respectful Open, explorative beginning |
Rapport |
Develops and sustains rapport |
Remains respectful and non-judgmental Genuine interest displayed by verbal and nonverbal responses Acknowledges patient’s distress with empathic responses |
Remains respectful and non-judgmental Genuine interest displayed by verbal and nonverbal responses Acknowledges patient’s distress with empathic responses |
Control of process |
Maintains control of the interview |
Interrupts politely when required Attempts to redirect when required |
Interrupts politely when required Redirects when required Facilitates organization of disorganized patients |
Cultural sensitivity |
Demonstrates cultural sensitivity |
Engages patient in a culturally safe manner |
Engages patient in a culturally safe manner |
Ends the interview |
Smoothly closes the interview |
Attends to timing Provides a pertinent closing statement |
Attends to timing Provides a pertinent closing statement |
2. Interview Technique
|
|
Foundations |
Core |
Item |
Expectation |
Criterion |
Criterion |
Information gathering |
Maintains an open, explorative process |
Non-verbal behaviour encourages patient to tell their story Listens attentively Note taking does not distract from the interview |
Non-verbal behavior encourages patient to tell their story Listens attentively Note taking does not distract from the interview |
Information gathering |
Uses a facilitative questioning style |
Questioning follows a logical sequence Asks clear questions in plain language Avoids leading questions Avoids stacked (multiple)questions Attempts to move between open and closed Facilitates expression of emotions |
Questioning follows a logical but flexible sequence Asks clear questions in plain language Avoids leading questions Avoids stacked (multiple)questions Moves effectively between open and closed questions Facilitates expression of emotion |
Information gathering |
Pursues important information |
Appropriately responds to informational and affective cues Attempts to pursue and clarify symptom detail |
Appropriately responds to informational and Pursues symptom detail Asks for clarification |
Maintains Flow |
Maintains Flow |
Reframes when required Summarizes when appropriate |
Supportively confronts inconsistencies Appropriately deals with unusual, difficult, or distressing content Comfortably allows silence to facilitate further expression Reframes when required Summarizes when appropriate |
3. Interview Content
|
|
Foundations |
Core |
Item |
Expectation |
Criterion |
Criterion |
Elicits a complete, relevant and accurate history |
Identifies the person |
Obtains demographic information |
Obtains complete demographic information |
Elicits a complete, relevant and accurate history |
Identifies the |
Obtains data on presenting complaint(s) or problem(s) Assesses pre-morbid state Assesses stressors related to presenting illness Inquires about previous illness episodes Inquires about past and present treatment interventions and response |
Obtains data on presenting complaint(s) or problem(s) Assesses pre-morbid state Assesses stressors related to presenting illness Assesses previous illness episodes if relevant, and determines similarities with/differences from this episode Identifies treatment interventions and response for this episode |
Elicits a complete, relevant and accurate history |
Screens for symptoms relevant to the differential diagnosis and identification of comorbid symptoms Ensures safety |
Screens for symptoms of relevant co-morbid illnesses, including mood, psychotic, and anxiety symptoms Inquires about substance use Completes an appropriate risk assessment (suicidal and homicidal ideation) Reviews current medication(s), dosage(s) and response Reviews use of over-the-counter products Assesses side-effects Inquires about allergies |
Reviews primary criteria of other relevant diagnoses Reviews substance use and abuse Assesses impact of substance use on person and others If appropriate, assesses motivation to change current substance use Completes an appropriate risk assessment (self-harm, aggression, self-care, and competency) Reviews current medication(s), dosage(s) and response Reviews use of over-the-counter products Elicits a complete, relevant and accurate history of side effects Defines allergy status |
Elicits a complete, relevant ad Elicits a complete, relevant and accurate history curate history |
Identifies relevant past history |
Reviews past medical history including family history of medical disorders Reviews past psychiatric history Reviews family psychiatric history |
Reviews past medical history including family history of medical disorders Reviews past psychiatric history Reviews family psychiatric history Reviews forensic history |
|
Identifies the developmental and psycho-social history |
Reviews family history Reviews birth history if relevant Inquires about childhood and adolescent development Reviews occupational history and current functioning Inquires about relationship status Inquires about abuse history Assesses current supports Inquires about other relevant social or cultural factors |
Review and assesses: Family history and dynamics Gestational and perinatal history Childhood and adolescent development Occupational history and current functioning Relationship history Past and current history of abuse Current supports Relevant cultural identities, migration history, and associated trauma and stressors Spirituality Identifies social and cultural supports including family, kin networks, and communities Identifies social and cultural stressors and systemic inequities Explores patient’s explanatory model of illness |
Conducts a formal Mental State Examination as indicated |
Conducts a formal Mental State Examination as indicated |
Assesses mood symptoms Assesses anxiety symptoms Assesses psychotic symptoms Assesses insight Assesses cognition if relevant Considers intellectual function if relevant |
Appropriately adapts the Mental Status Examination to be culturally competent Assesses mood symptoms Assesses anxiety symptoms Assesses psychotic symptoms Assesses insight and judgment Assesses cognition if relevant Considers intellectual function if relevant |
4. Case Presentation
|
|
Foundations |
Core |
Item |
Expectation |
Criterion |
Criterion |
Defines limitations of the data |
Identifies issues in the information gathering process |
Reflects on patient reliability if indicated Identifies deficits in the interview and their potential effect on the data collection |
Reports on the reliability of the patient (with examples) Reports on the accessibility of the patient (with examples) Identifies deficits in the interview and their potential effect on the data collection |
Presentation skills |
Provides a coherent, accurate summary of the case |
Uses descriptive terms correctly (e.g., delusions) Presents case in an organized manner that is sufficiently detailed Accurately reports the Mental State Examination Accurately reports the risk assessment (suicidal, homicidal, and self-harm ideation) Considers relevant comorbidities |
Uses descriptive terms correctly (e.g., delusions) Presents case in an orderly, concise, systematic manner that is sufficiently detailed Accurately reports the Mental State Examination Accurately reports the risk assessment (self-harm, aggression, self-care, competency) Identifies relevant comorbidities |
Synthesizing skills |
Synthesizes all the clinical information into a diagnosis, differential diagnosis, and case formulation |
Presentation includes information to support the preferred diagnosis and differential Provides a probable working diagnosis including co-morbidities supported by evidence from the interview Provides a differential diagnosis supported by evidence from interview |
Presentation emphasizes the necessary information to support and defend the preferred diagnosis and differential Provides a working diagnosis including co-morbidities supported by evidence from the interview Provides a differential diagnosis supported by evidence from interview Discusses co- morbidities and interplay between diagnosis Provides a realistic prognosis Describes barriers to compliance or optimal treatment for this patient |
Synthesizing skills |
Presents a formulation covering the rudimentary biopsycho-social factors influencing the patient and their disorder |
Identifies some contributing: Biological factors Psychological factors Social Cultural factors Starts to consider the interplay between these components |
Identifies contributing: Biological factors Psychological factors Social factors Cultural factors Provides a sophisticated and accurate account of the interplay between these components that enhances the understanding of the patient Identifies prominent internal conflicts and/or cognitive distortions that influence the patient’s presentation |
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|
|
|
5. Treatment Plan
|
Foundation |
Foundation |
Core |
Core |
Item |
Expectation |
Criterion |
Expectation |
Criterion |
Presents a coherent, safe and appropriate treatment plan |
Identifies information required to consolidate the diagnosis |
Identifies bio- psycho-social investigations required to confirm the diagnosis or provide optimal care to the patient |
Identifies information required to consolidate the diagnosis |
Identifies further, appropriate, and cost effective bio- psycho-social investigations required to confirm the diagnosis or provide optimal care to the patient |
Presents a coherent, safe and appropriate treatment plan |
Communicates a safe multimodal treatment plan |
Presents an immediate and short term treatment plan Suggests specific biological therapies for the patient Suggests specific nonpharmacological interventions for the patient, including psychotherapeutic approaches and social and culturally safe interventions |
Communicates a comprehensive treatment plan |
Utilizing a bio-psycho-social matrix defines an immediate,short- term, and long-term treatment plan Recommends specific biological therapies (pharmacotherapy, ECT, TMS, etc.) for the patient Recommends a specific psychotherapeutic approach for the patient Considers social and cultural factors in all aspects of treatment planning Identifies appropriate collaborations with family, community or other service providers Provides evidence for the efficacy of treatment plan Identifies the expected benefits and risks of the treatment plan Identifies the follow-up procedure |