Educational Principle

Why Field Notes?

Using DOFN provides the following advantages: · an opportunity to have a direct observation/discussion format at our fingertips · an ongoing record of residents’ experience · a method for giving appropriate feedback to individual residents · a focus on skills/objectives identified by external licensing bodies · a way of teaching clinical problem solving/reasoning · improved consistency of objectives/goals throughout the program · a method for residents to provide us with feedback when they observe our interactions with patients and staff.
The following form is a useful way of organizing the note. A pad of such notes fits easily into a pocket.

Using Field Notes

1. Plan when and how the field notes will be used

The preceptor can use the notes when they are observing an entire patient encounter, observing part of an encounter or when discussing a case. Encourage the resident to request observation/discussion whenever opportunities arise. Regular discussion of cases (see Teaching on the Fly module) will improve the student’s clinical reasoning and problem solving. CFPC standards require one direct observation/week. Notes can be stored until the mid rotation with either the student or preceptor. At mid and end of rotation, DOFN should be turned into the site administrator for storage in student’s files.

2. Fill out the front of the form

• Write in the date, names, patent’s initials, gender, age, and diagnosis/procedure
• Circle the word observed or discussed depending on what was done to keep track of the number and type of encounter
• Check off the appropriate phase of the encounter (i.e. History-Follow-up)
• Make the task more manageable by focusing on only one or two of the following dimensions per session :
  
  • Selectivity: the ability to discern what is important and what is unimportant with appropriate attention to detail and thoroughness
  • Clinical Reasoning: this is the bulk of our clinical work. Anything traditionally identified as clinical problem solving falls in to this category
  • Professionalism: everything related to professional competence from appearance to ethics
  • Patient centered approach: six aspects of patient centered clinical method
  • Psychomotor Skills: procedure and exam skills
  • Communication Skills: including all domains not included in the patient centered approach (family of patients, staff, colleagues)

3. Use the back of the note to provide feedback

• Use any combination of the prompts at the back to provide feedback to the resident:

• Continue: for things they are doing well and should keep doing because they may not realize they are performing well in this area, e.g. “I noticed that the patient seemed to appreciate your explaining what you were doing during the procedure.”
• Do more: for suggestions you might have for improvements, e.g. “Keep steady pressure on the Pipelle until internal os relaxes”
• Consider: for learning objectives for the next time, e.g. “Review the guidelines for hypertension in diabetics.”
• Stop: for anything they are doing that is inappropriate, e.g. “The term spontaneous abortion can be upsetting to pts-try using miscarriage.” ·
• Use RIME at the bottom of the feedback section as an optional way of helping learners identify the level of their proficiency in clinical reasoning:
  
  • Reporter: at this level, the learner can collect information but not consistently use this information to formulate a diagnosis
  • Interpreter: here the learner can collect and use the information for differential and diagnosis
  • Manager: is able to do the above plus formulate adequate treatment and follow-up plans
  • Educator: is able to provide the patient and other medical students with appropriate evidence-based education and empower patients to engage in negotiated treatment and follow-up plans.

4. Review for mid/end of the rotation

• Ensure that a variety of skills and clinical situations have been covered by the direct observations/discussions
• Turn them into the site administrator for storage in student’s files.

Note via email about where this originated
The field note you have with the instruction sheet are an older version of ours at Dalhousie. Cathy Cervin and I developed this version using information from the CFPC WGCP (Working Group Certification Process) and the information kindly provided to us from the originator of the field note in Family Medicine Mike Donoff.

Mike first published an article in 1990 in CFP called "The Science of In-Training Evaluation" that described a qualitative method approach to resident evaluation and referred to field notes as a tool. He (U of Alberta) started their first work on field notes in 1989. I.e. twenty years ago! He has done focus groups to assess how learners and preceptors used field notes but has never published these. He was a member of the CFPC Task Force on In Training Evaluation and that report referred to using field notes reflecting on his experience with them.

Resources

Mini CEX very good resource with videos


Pilot of Direct Observation of Clinical Skills (DOCS) in a Medicine Clerkship: Feasibility and Relationship to Clinical Performance Measures PDF

Effects of Training in Direct Observation of Medical Residents' Clinical Competence

Direct Observation of Procedural Skills (DOPS). Critical Care Medicine. Form

Direct Observation in Medical Education: A Review of the Literature and Evidence for Validity

Effects of Training in Direct Observation of Medical Residents’ Clinical Competence

Tools for Direct Observation and Assessment of Clinical Skills of Medical Trainees

Mini Clinical Evaluation Exercise (form)