Evaluator: TJH Date: 11/26/19 Description: Ankle spr, ES, comp, cp, etc Evaluation Items Yes =1 ;No = 0 Comment/Observation Professional Behaviors Proper Introduction 1 Verifies ID & Informed Consent 1 Agreement to Treat 1 Language appropriate to Pt 1 Confident & Positive 1 Patient Positioning Appropriate transfer or assistance 1 Appropriate for condition 1 Checks on Pt comfort 1 Protect PT body mechanics 1 Appropriate Draping (if required) 1 Allows for efficient delivery of Tx 1 Patient Information/Instruction Description of Modality and Tx 1 Goal of Tx 1 Contraindications/Precautions 1 What Pt should expect to feel 1 Safety switch or shut-off (if required) 1 Application of Modality(ies) Appropriate for age, sex, condition 1 Appropriate for contraindications 1 Appropriate rationale for set-up 1 Appropriate dose 1 Appropriate accessory equipment 1 consider including compression to incr effect Able to ascertain changes in Pt 1 Appropriate technique/delivery 1 Appropriate management of skin 1 Followed all safety measures 1 Score/Result 25 General Comment/Observation ≥ 80% to pass 100% well done, efficient, good communication Technical Result Pass Safety Result Pass ubric (25 points max)