Healthcare Core Competency Exam

HEALTHCARE CORE COMPETENCY EXAM

This document records the standardized patient registration, informed consent, and the documented results of the Healthcare Core Competency Exam administered for educational, quality assurance, and credentialing purposes. Participation is voluntary. The standardized patient hereby authorizes use of protected health information created or disclosed in connection with this examination as described in the HIPAA Authorization section below.

Patient Information

Date of Birth:     Gender: Male Female Other

Insurance Information

Medical History (Standardized Patient)

Exam Administration

Facility / Program:     Exam Date:

The standardized patient affirms that he or she understands the purpose of the exam, the procedures to be performed, and the educational use of the information gathered. Participation is voluntary and may be withdrawn at any time without penalty.

Consent to Participate: I consent to participate in this standardized patient encounter and to the recording of observations for training and assessment purposes.

Audio/Video Recording: I permit audio/video recording during the exam.     If not permitted, check here:

HIPAA Authorization / Release for Educational Use

I authorize the release of my protected health information (PHI) generated during this examination to the facility and its authorized instructors, evaluators, and accrediting bodies for the sole purposes of education, competency assessment, quality improvement, and credentialing. Information disclosed may include medical history, examination findings, and audio/video recordings of the encounter.

I understand that the information will be used in a controlled educational context and that reasonable administrative and technical safeguards will be applied to protect confidentiality. I further understand that I may revoke this authorization in writing at any time, except to the extent that action has already been taken in reliance on the authorization.

Authorization Expiration Date:

Core Competency Assessment

Evaluator to mark Pass / Fail / Not Observed, provide brief comments, and assign a numeric score for each competency area. Scores are used for formative and summative evaluation consistent with program policy.

Pass Fail Not Observed     Score:

Pass Fail Not Observed     Score:

Pass Fail Not Observed     Score:

Pass Fail Not Observed     Score:

Attestation: I certify that the information provided on this form is true and accurate to the best of my knowledge and that I have received the information described above.

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