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FUNDAL EXAMINATION: INDIRECT OPHTHALMOSCOPY / T-MIRROR ICO WORKPLACE BASED ASSESSMENT DIRECT OBSERVATION OF PROCEDURAL SKILL (DOPS) Trainee’s Name BST1 BST2 Date (dd/mm/yyyy) BST3 BST4 BST5 BST6 Other (specify) Assessor’s name Assessor’s status Consultant Trainee Other (specify) Brief description of case and Learning Outcome Please grade the following areas using the scale below (use tick or cross) Attitude and manner V good trainees introduce themselves and establish the identity of the patient and any other attendant (e.g spouse, parent or carer). Their demeanour throughout shows they are attentive to the patient by gestures, words of encouragement and appropriate eye contact. They clearly explain the purpose of the test and how it will be carried out. They ensure that the patient is comfortable and that adequate privacy is maintained. Good trainees introduce themselves and establish the identity of the patient and any other attendant (e.g. spouse, parent, carer). Their demeanour varies, sometimes demonstrating active listening, sometimes less aware of the patient’s concerns. They establish a good rapport overall, although there may be instances of poor understanding. They clearly explain the purpose of the test and how it will be carried out. They make some effort to ensure patient is comfortable. They maintain adequate privacy. Fair trainees may not introduce themselves or establish the identity of the patient and any other attendant (e.g. spouse, parent, carer) well, for example, may introduce themselves by first name without explaining his/her role (SHO, registrar, etc.), or may presume the attendant is to stay with the patient for the consultation without determining the patient has consented to this. They explain the test in a superficial way and can be vague about how it will be carried out. Their demeanour may appear abrupt at times and they may miss important information/concerns that the patient expresses. They may be inconsiderate of patient preferences. They may only partially ensure privacy. Poor trainees fail to introduce themselves and do not identify the patient. They appear to hurry or ignore what the patient is saying. They do not explain the test in an appropriate manner. They pay little or no attention to confirmation of patient comfort or privacy. Poor Fair Good V Good n/a Introduction and explanation of examination Rapport with patient, empathy and sensitivity to age and context Indirect ophthalmoscopy V good trainees adjust the equipment appropriately before use, in particular adjusting the light and IPD for optimum viewing. They examine the patient in a reclined position whenever appropriate and ensure their comfort. They choose the most appropriate condensing lens, correctly explaining their choice of lens. They demonstrate an efficient and fluent technique, holding the lens at the best distance from the patient’s eye. They approach the examination in a logical sequence ensuring they view all 4 quadrants in the most anterior as well as the posterior parts of the retina. They ask the patient to look in appropriate directions in order to view relevant parts of the retina and move their body accordingly. When appropriate they use indentation efficiently and gently. They use the minimum light necessary for a proper view and empathize with the patient when the light or the indentation causes discomfort. They are able to accurately and without hesitation describe and draw any relevant lesions with a clear understanding of image inversion as well as lateral reversal of the image. Good trainees adjust the equipment appropriately before use, in particular adjusting the light and IPD for optimum viewing. They examine the patient in a reclined position whenever appropriate and ensure their comfort. They may not choose the most appropriate condensing lens and are unsure in explaining their lens selection. Their technique is generally efficient but not always fluent, and may be hesitant. Usually they hold the lens at the best distance from the eye but may need to check and re-check themselves in order to do this. They initially approach the examination in a logical sequence but fail to continue in such a manner, and only adequately view 3 of the 4 quadrants in the most anterior as well as the posterior parts of the retina. They ask the patient to look in appropriate directions in order to view relevant parts of the retina. When appropriate they use indentation but find it difficult and may have technique which is sub-optimal. They use the minimum light necessary for a proper view and empathize with the patient when the light or the indentation causes discomfort. Their description and drawing of their findings is generally accurate but may have minor flaws or omissions. If they make an error in the retinal drawing of their findings they quickly correct themselves without prompting from the assessor. Fair trainees place the ophthalmoscope in position on their head squarely and securely. They take time to adjust the light and IPD appropriately and may not achieve an optimal view. They may fail to ensure that the patient is comfortable or appropriately positioned, often because of concentration on the technical aspects of the task. It takes them a while to figure out the correct illumination, and this might result in the patient having minor discomfort. Their use and positioning of the lens is haphazard and lacks confidence. They approach the examination in an interrupted fashion without a logical sequence. They only adequately view 2 of the 4 quadrants but fail to view the inferior and temporal or nasal retina properly. They adequately view the posterior parts of the retina but viewing of the anterior retina is incomplete. They go through the motions of asking the patient to look in appropriate directions in order to view relevant parts of the retina but they do not move their body to optimize the view. They make an attempt at indentation but it looks unpracticed and the examiner may need to assist. They can be unconvincing when showing empathy. They can identify that abnormalities are present but are unable to describe and draw them accurately without prompting from the assessor. Poor trainees struggle to place the ophthalmoscope in position on their head squarely and securely. They are unable to adjust the light and IPD appropriately. They fail to ensure that the patient is comfortable or appropriately positioned. They use too much or too little illumination. Their use and positioning of the lens is haphazard. They are unable to co-ordinate an examination of the peripheral fundus and are rough with and/or unsuccessful at indentation, requiring the examiner to take over. They fail to understand and empathize with the patient when they fail to achieve a view. They miss abnormalities altogether and/or fail to describe them. Poor Fair Good V Good n/a Knowl Instructions to patient Familiarity with use of ophthalmoscope Correct use of illumination and appropriate use of lenses Technique to view posterior pole (focus) Technique to view each quadrant in different positions of gaze Indentation technique and ability to view anterior retina Description and drawing of retinal findings T-mirror V good trainees set up the slit lamp illumination and eyepieces before commencing the examination. They help the patient to get into position if necessary. They warn the patient of the brightness of the light. They ensure that the patient's ocular surface is adequately anaesthetized. They ensure the lens is disinfected and clean. They choose the most appropriate colour, size and brightness of light at every stage and empathize with the patient who has difficulty keeping the eye still. Their technique is fluent and they are able to view all structures required. They are clear which part of the retina is viewed through each mirror. They clearly understand image inversion and can accurately describe both the location and orientation of observed retinal lesions. Good trainees set up the slit lamp illumination and eyepieces before commencing the examination. This might take some deliberation and be slower than desired. They help the patient to get into position if necessary. They warn the patient of the brightness of the light. They ensure that the patient's ocular surface is adequately anaesthetized. They ensure the lens is disinfected and clean. They may not always choose the most appropriate colour, size and brightness of light. They empathize with the patient who has difficulty keeping the eye still. Their technique is adequate but lacks fluency and may have some aspects which are awkward. The lens may come off but they are able to reassure the patient and proceed with reinsertion without becoming distracted. They are clear which part of the retina is viewed through each mirror. They are able to view most structures required and describe their location with general accuracy but missing some finer points on orientation. They correct themselves without prompting from the assessor. Fair trainees either spend too long setting up the equipment or do it sloppily. They might start with an inappropriately bright light so it might take some time to adjust appropriately, or they might use an appropriate light but be slow and hesitant in proceeding. Their empathy towards the patient may seem robotic or an afterthought and they may not be able to reassure the patient adequately during the procedure. They may have suboptimal disinfection procedures. The lens may come off the eye and they have difficulty with reinsertion. They are unclear which part of the retina is viewed through each mirror and require prompting. They will usually achieve a view and identify there is an abnormality but only with effort. They fail to describe abnormalities accurately in terms of location or orientation and require prompting form the assessor. Poor trainees rush into the examination without setting the slit lamp properly. They start with an inappropriately bright light. They show frustration when patients cannot place their head appropriately, cannot hold their eye still or have difficulty tolerating the contact lens. They show no regard to disinfection procedures. They have difficulty getting the lens positioned correctly and have reinsert it multiple times. If they manage to achieve a view at all they miss abnormalities altogether and/or fail to describe them accurately in terms of location or orientation. Poor Fair Good V Good n/a Appropriate ambient lighting and slit-lamp illumination (1mm) Application of anaesthesia / coupling fluid Knowledge of fundal view for each mirror Fluency of technique, rotation of lens, duration of examination Knowledge of orientation of image and accurate clinical drawing Description of findings Overall difficulty of case Simple Intermediate Poor Overall performance in this assessment Outcome (Delete as appropriate) Difficult Fair Good V Good Competent/Not competent Please use the boxes below/overleaf for free-text comments and recommendations for further training. Anything especially good? List 2 action points which the trainee should take to improve by time of next assessment: 1. 2. Signature of assessor: Signature of trainee