Student: ____________________________ Evaluator:____________________________ Campus: KC W Date:_____________
|
____ Ambulatory Med./Geriatrics ____ Family Medicine |
____ Internal Medicine ____ Neuropsychiatry |
____ Obstetrics/Gynecology ____ Pediatrics |
____ Surgery ____ Other: ____________________ |
Overall summary score: ___________________
DIRECTIONS: Please circle the statement that best describes the student's performance.
| PATIENT CARE: Student is learning the skills necessary to provide care that is compassionate, appropriate, and effective. |
HISTORY TAKING / REVIEW OF DATA
|
Incomplete, Inaccurate, disorganized |
Frequently misses relevant data; may not focus on key areas |
Adequately elicits relevant data |
Elicits data in highly satisfactory manner, usually accurate & complete |
Exceptional ability to elicit a thorough history, very well organized |
Not Observed / Not Applicable |
EXAMINATION (general physical examination and focused exam, e.g., mental status exam, pelvic exam, pregnant woman exam, etc.)
|
Often misses major, important findings |
Frequently makes inaccurate findings |
Satisfactorily identifies findings accurately |
Highly satisfactory in accurately identifying important findings |
Excellent ability to accurately identify physical findings |
Not Observed / Not Applicable |
CLINICAL REASONING
|
Illogical or little effort made |
May be illogical or impractical |
Typically logical & practical, but with significant error rate |
Usually logical & practical with low error rate |
Accurate and insightful |
Not Observed / Not Applicable |
| MEDICAL KNOWLEDGE: Student is learning to apply their knowledge of biomedical, clinical, and social sciences effectively to patient care. |
Preparation for Rounds/ Small Groups / didactics
|
Usually unprepared, poor understanding of disease processes |
Fair preparation; minor deficiencies in understanding of disease processes |
Adequately prepared, adequate understanding of disease processes |
Well prepared, highly satisfactory understanding of disease processes |
Exceptionally well prepared, excellent understanding of disease processes |
Not Observed / Not Applicable |
| PRACTICE BASED LEARNING & IMPROVEMENT: Student is learning to use evidence and methods to investigate, evaluate, & improve patient care. |
SELF-EVALUATION / SELF-AWARENESS
|
Lacks insight, resists/ignores feedback |
Limited insight; resists/ignores some feedback |
Average insight; incorporates some feedback |
Good insight, incorporates feedback |
Exceptional insight, incorporates feedback |
Not Observed / Not Applicable |
USE OF TOOLS/INFORMATION TO IMPROVE THEIR KNOWLEDGE, SKILLS & ATTITUDES
|
Fails to use information technology. |
Limited use of information technology. |
Average use of technology. |
Good use of technology. |
Outstanding use of technology. |
Not Observed / Not Applicable |
| Interpersonal & Communication Skills: Student is learning effective communication skills and maintains professional and therapeutic relationships. |
RAPPORT / Relationships with others
|
Relationships are dysfunctional. |
Relationships are superficial or awkward. |
Adequate professional relationships, empathy & rapport. |
Highly satisfactory rapport & empathy. Relationships are professional. |
Exceptional at establishing therapeutic relationships & working with the team. |
Not Observed / Not Applicable |
| Interpersonal & Communication Skills: Student is learning effective communication skills and maintains professional and therapeutic relationships. |
Oral & Written communication
|
Disorganized, unable to communicate thoughts & facts. Uses incorrect & vague terminology, illegible. |
Often illegible or inaccurate. May be disorganized & may use incorrect & vague terminology |
Clear, organized; accuracy is satisfactory, adequate synthesis |
Well organized, accurate & shows good synthesis. |
Remarkably well organized, concise, accurate, shows outstanding synthesis
|
Not Observed / Not Applicable |
| Professionalism: Student demonstrates behaviors that reflect ongoing commitment to continuous professional development, ethical practice, & sensitivity to diversity. |
RELIABILITY/DEPENDABILITY/HONESTY
|
Lacks integrity and dedication, unreliable. |
Marginal dedication, reliability & integrity. |
Dependable; honest, reliable. |
Very Dependable, reliable, & dedicated. |
Remarkable dedication, reliability and integrity |
Not Observed / Not Applicable |
RESPECT FOR PATIENTS & FAMILIES
|
Disrespectful; Doesn't maintain patient confidentiality. |
Superficial engagement with patient and families. |
Respectful; maintains patient confidentiality. |
Very respectful and sensitive to patient needs. |
Keenly aware of patient/family concerns, remarkably skillful at assessing patient issues. |
Not Observed / Not Applicable |
| Systems-Based Practice: Student is learning to understand and demonstrate knowledge of optimal health care delivery. |
Health Care Delivery System
|
Does not understand the role of non-physician team members. |
Unsure of all team member roles or how best to utilize them. |
Can define the role of team members. Satisfactory understanding of systems for health care. |
Can define the roles of team members. Highly satisfactory understanding of systems for health care. |
Exceptionally effective at consulting with health care team to provide optimal patient care. |
Not Observed / Not Applicable |
| Overall clinical PERFORMANCE RATING (US or LS ratings suggest remedial work is needed) | ||||
|
Unsatisfactory (59% & Below) |
Low Satisfactory (60% - 69%) |
Satisfactory (70% - 79%) |
High Satisfactory (80% - 89%) |
Superior (90% - 100%) |
|
Required
comments that maybe used for Chairman's and/or Dean's Letter
|
General comments not intended for Chairman's and/or Dean's Letter |
By signing below you are indicating that the ratings above were discussed with the student.
Student signature _____________________________________ Evaluator signature _____________________________________
Status: [ ] Faculty Member, [ ] Resident, [ ] Other: ___________________
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