EPA: RLQ pain/appendicitis

Evaluatee Name (Last, First)*

Enter resident starting with last name. Once a form has been submitted, the resident will receive a copy of the evaluation.

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Phase of Care

UPDATE! You can only select one phase of care. Complete an assessment for each phase of case separately.

Intraoperative

Postoperative

Preoperative/Nonoperative

For each category, select the statement that best describes the resident behavior for this patient encounter.

Preoperative: Evaluation*

OBTAINS AN H&P with cultural humility and DEVELOPS A DIFFERENTIAL for a patient with RLQ pain

Evaluates a patient with appendicitis, DETERMINES WHEN IMAGING IS INDICATED, and INTERPRETS LAB VALUES AND STUDIES. DEVELOPS A PLAN for managing a patient with uncomplicated appendicitis

DEVELOPS A PLAN FOR MANAGING A STRAIGHTFORWARD patient with complicated appendicitis.

INITIATES A COST-EFFECTIVE WORKUP; uses available technologies when a diagnosis is in doubt

Not applicable/not observed

Preoperative: Communication with Patient*

Respectfully COMMUNICATES BASIC FACTS about the condition but INCONSISTENTLY USES APPLICABLE LANGUAGE SERVICES & AUDIO/VISUAL AIDS.

CUSTOMIZES COMMUNICATION to overcome barriers (literacy/language/cultural differences); uses language services & audio/visual aids to elicit preferences.

Elicit personalized care plan in shared decision-making process for straightforward presentation.

Customizes communication based on individual patient characteristics/preferences across barriers/cultural differences in COMPLEX OR LIFE-THREATENING SITUATION; manages/de-escalates conflict with a difficult or hostile patient/caregiver.

Not applicable/not observed

Preoperative: Informed Consent*

Communicates elements of informed consent discussion but OMITS SOME ELEMENTS when documenting discussion

Communicates elements of informed consent discussion FOR STRAIGHTFORWARD APPENDECTOMY (UNCOMP PT) & completely documents discussion

Communicates elements of informed consent discussion for straightforward appy w/ cultural humility, INDIVIDUALIZING RISKS/BENEFITS/ALTERNATIVES; completely documents the discussion

Communicates elements of informed consent discussion for COMPLEX OR EMERGENT APPENDECTOMY with cultural humility; elicits patient preferences; documents risks/benefits individualized to the patient

Not applicable/not observed

Preoperative: Medical Knowledge*

Demonstrates understanding of BASIC PATHOPHYSIOLOGY of the appendix and other RLQ organs and uses this knowledge to consider other causes of RLQ pain, including some of the most common disorders

Develops BROAD DIFFERENTIAL when evaluating RLQ pain, including conditions that can masquerade as appendicitis (Crohn's, typhlitis, lymphoma in HIV). Applies knowledge of anatomy/physiology when evaluating RLQ pain (eg, psoas sign, rectal or pelvic exam).

SYNTHESIZES KNOWLEDGE of patient factors, comorbidities, anatomy, and physiology when developing a differential and treatment plan

MANAGES A COMPLICATED PRESENTATION, considering op & nonop management strategies (IR drainage of perforation/abscess or nonop management for high-risk pt w/ uncomp appendicitis. Manages complex comorbidities (preg, IBD, anticoag req reversal)

Not applicable/not observed

Preoperative: Evidence-Based Practice*

Accesses evidence about treatment options to manage appendicitis but REQUIRES GUIDANCE TO SELECT AN APPROACH

INCORPORATES PUBLISHED GUIDELINES and scoring systems regarding the workup and management of appendicitis and applies them with guidance

APPLIES PUBLISHED GUIDELINES REGARDING THE WORKUP AND MANAGEMENT of a complex presentation of appendicitis; INCORPORATES PATIENT PREFERENCES into the plan

Applies current published guidelines and scoring systems regarding the workup and management of appendicitis, considering nuances and exceptions in a COMPLEX SITUATION

Not applicable/not observed

Intraoperative: Anatomy*

Identifies the layers of the abdominal wall at the midline and RLQ.

LOCATES THE APPENDIX despite anatomic variants (ie, retrocecal). Identifies tissue planes that have not been previously dissected but NEEDS ASSISTANCE to identify or manage variable anatomy or tissue planes in a REOPERATIVE FIELD.

Locates the appendix, EVEN WITH INFLAMMATION OR SCARRING.

Manages VARIABLE ANATOMY IN A REOPERATIVE FIELD. Accesses the abdomen safely in a patient with PRIOR ABDOMINAL OPERATIONS OR DURING PREGNANCY.

Intraoperative: Steps of Operation*

DESCRIBES THE KEY STEPS of an appendectomy and how to locate the appendix in the normal position. REQUIRES ACTIVE INSTRUCTION to move the operation forward.

PROVIDES A BASIC DESCRIPTION of the operative plan but OMITS SOME STEPS. Anticipates some next steps in operation & necessary instruments. Moves the operation forward, USUALLY PROCEEDING TO NEXT STEP of the procedure, though sometimes requires direction.

MOVES FLUIDLY THROUGH THE OPERATION, anticipating next steps and logistical needs and clearly communicating these needs to the OR team

DEVISES AND IMPLEMENTS A PLAN WHEN DEVIATION from the initial operative plan is required (eg, conversion to open). Analyzes how the choice of instrumentation will affect the overall cost of the procedure.

Intraoperative: Preventing Errors*

Places subsequent laparoscopic trocars after initial entry; REQUIRES GUIDANCE TO PREVENT IATROGENIC INJURY and target the area of dissection.

Identifies positioning options but cannot name factors to select one over another; recognizes importance of protecting against nerve/pressure injuries but cannot describe resulting morbidity. REQUIRES ASSISTANCE TO ENTER THE ABDOMEN OR CONTROL BLEEDING.

DESCRIBES a systematic APPROACH TO EXPLORING ALTERNATE PATHOLOGY when the appendix appears normal.

IMPLEMENTS a systematic APPROACH TO EXPLORING ALTERNATE PATHOLOGY (eg, alternative trocar and patient positions) when the appendix is normal.

Intraoperative: Technical Skills*

Understands how to use angled laparoscope; centers field (freq adjustments). CLOSES WOUNDS UNDER SUPERVISION; demonstrates sharps safety/surg energy use/surg field sterility. Displays COORDINATED BUT INEFFICIENT HAND MOVEMENTS in simple maneuvers.

Performs suturing/knot tying. Places trocars after initial entry; closes skin independently. Guidance for port site triangulation & safe abd entry. Careful tissue handling & 2-hand coordination. Maintains but not initially identifies dissection plane.

PERFORMS STRAIGHTFORWARD LAP APPY. Smoothly maneuvers scope & instruments most of the time, good hand coordination. Maneuvers SB/colon/omentum w/o excessive force. CONSISTENT CAREFUL TISSUE HANDLING; IDENTIFIES DISSECTION PLANE (ROUTINE case).

Performs appendectomy w/ SIGNIFICANT INFLAMMATION OR ADHESIONS FROM PRIOR OPERATIONS. Demonstrates CAREFUL TISSUE HANDLING & plane development in BOTH NL & ABNL TISSUE (cecum & appendix); adapts technique & instruments as necessary.

Postoperative: Communication with Patient*

Communicates BASIC ASPECTS OF THE OPERATIVE PROCEDURE to a patient/caregiver(s) but needs prompting to clarify expected outcomes and the anticipated treatment course

Communicates DETAILS OF THE OPERATIVE PROCEDURE to a patient/caregivers) but OMITS SOME ELEMENTS WHEN DISCUSSING EXPECTED OUTCOMES and the overall anticipated treatment course

Interprets and communicates straightforward pathology accurately. Communicates Unexpected Findings Or Changes to the intended plan to a patient/caregiver(s) with cultural humility

MANAGES CONFLICT between patient/caregiver(s) and health care team. CUSTOMIZES EMOTIONALLY DIFFICULT NEWS (eg, changes to the operative plan, adverse outcome, end-of-life discussion) to a patient/caregiver(s) in a culturally dexterous and caring manner

Not applicable/not observed

Postoperative: Complications*

EVALUATES GENERAL VARIANCES in the standard immediate postop course, such as fever, hypotension, or urinary retention, REQUIRING SUPERVISION TO MANAGE THEM. Alerts supervisors about postop complications and initiates management with supervision

IDENTIFIES WHEN A PATIENT DEVIATES from a normal postop recovery pattern but OMITS SOME ELEMENTS from the differential

RECOGNIZES ALL POSTOP COMPLICATIONS (sepsis or deep or superficial SSI) & completes necessary w/u for these problems independently in UNCOMP PT. EVALUATES POSTOP PROBLEMS in a patient with a COMPLEX MEDICAL CONDITION, requiring supervision to manage them

IDENTIFIES, EVALUATES, AND INDEPENDENTLY MANAGES complex immediate and delayed postop complications (fistulas and dehiscence). Directs interdisciplinary care to manage a patient experiencing complications.

Not applicable/not observed

Postoperative: Patient Care*

INITIATES POSTOP PATHWAYS, including multimodal pain management and discharge

DEVELOPS A DISCHARGE PLAN that includes pain management and is based on the hospital course and the patient's disease. MANAGES A SIMPLE POSTOP PROBLEM independently (eg, fever, tachycardia)

Prepares and CUSTOMIZES A DISCHARGE PLAN for a patient with a COMPLICATED COURSE

Elucidates initial therapy for pathology other than appendicitis when indicated

Not applicable/not observed

Postoperative: System Based Practice*

Describes different models of health care coverage in the U.S. and BASIC COMPONENTS OF DOCUMENTATION REQUIRED FOR BILLING AND CODING for appendicitis

Recognizes the INFLUENCE OF HEALTH CARE SYSTEM FINANCING STRUCTURES ON THE POSTOP CARE of a patient with appendicitis (eg, global period, care of patient requiring initial percutaneous drainage)

Analyzes how DIFFERENT TREATMENT STRATEGIES (operative vs nonoperative management) IMPACT OUTCOMES AND COSTS OF CARE

Selects a method of POSTOP FOLLOW-UP, CONSIDERING CASE COMPLEXITY, health care system cost, and PATIENT WISHES AND RESOURCES (telehealth, transportation challenges

Not applicable/not observed

Overall Performance*

Based on your observation, what level of autonomy would you trust the resident to perform this task at the NEXT encounter?

Limited Participation: Learner has basic knowledge and skills, attending does show and tell

Direct Supervision: Attending provides active help

Indirect Supervision: Attending provides passive help

Practice Ready: Attending is available but is not needed for routine cases/presentations, but input may be needed for complex cases

Comment*

Please add comment on why you selected the answer above. Specifically note what steps the resident can take to achieve the next level of autonomy.