OBGYN Provider Follow-up - word

Form Approved

OMB No. 0920XXXX

Exp. Date xx/xx/20xx

CDC estimates the average public reporting burden for this collection of information as 3 minutes per survey, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden

to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D74,

Atlanta, Georgia 30333; ATTN: PRA

(0920XXXX).

OBGYN BI-MI Proficiency Rating Scale (PRS) – Provider/Trainee Follow-Up (3m and 6m)

Instructions:
Please indicate how well you did each of the following during your most recent brief intervention with a patient in your clinic regarding alcohol use.

Use the following anchors for items 1-10 and please note that Item 11 has its own set of anchors below it.

1 = I did not do this.
2 = I attempted, but could improve on skill/technique for best practice.

3 = I performed this skill/technique at a level that is approaching acceptable.

4= I did this well, with good technique.

5 = I did very well, with positive reception & engagement from the patient.

Ask for permission to talk about patient’s alcohol use.	1	2	3		4		5
Assess quantity, frequency, & consequences of alcohol use.	1	2	3		4		5
Explain NIAAA low risk drinking guidelines (including “0 drinks for pregnant women” and associated health risks.	1	2	3		4		5
Advise the patient to quit or cut down on alcohol use.	1	2	3		4		5
Help her think about pros & cons of her alcohol use.	1	2	3		4		5
Ask how ready she is to make a change.	1	2	3		4		5
Help the patient make a plan or set a goal for decreasing use and/or discussing further.	1	2	3		4		5
Explore patient’s own reasons for quitting or cutting down on alcohol use.	1	2	3		4		5
Work with the patient as a partner (respectfully and non-judgmentally) in addressing her alcohol use issues.	1	2	3		4		5
Support her autonomy and choice regarding substance use.	1	2	3		4		5

11. Because of this conversation, the patient’s motivation to cut down or
    quit using alcohol, or at least to consider doing so, was increased.
    
    1 2 3 4 5

Strongly Disagree Neutral Agree Strongly
Disagree Agree

Thanks for your participation and feedback!