IN-TRAINING ASSESSMENT REPORT
Trainee Name:
Rotation: Ambulatory Pediatrics
Trainee Level:
Start Date:
End Date:
Block(s):
Goals & Objectives:
Considering the present level of training and, on review of training milestones, assess the
resident performance in the following areas:
1*
unsatisfactory
2
marginal
3
good
4
very good
5
excellent
well below expected
level
additional work
needed
performance at the
expected level
area of strength
exceptional
performance
* must provide comment when selecting
Medical Expert
1*
2
3
4
5
NA
Demonstrates an appropriate pediatric knowledge base.
Gathers relevant information (e.g. through history and physical) and
uses that information to generate appropriate differential
diagnoses.
Demonstrates knowledge of normal range of findings in the
physical examination of children.
Demonstrates knowledge of normal childhood growth and
developmental milestones.
Demonstrates skill in the provision of period health exams to infant,
children and adolescents.
Utilizes common screening tests, including for scoliosis,
strabismus, hearing, blood pressure, etc.
Demonstrates knowledge of immunization protocols and the risks,
benefits and adverse effects of immunization.
Integrates health promotion for varying age groups [e.g., healthy
active living, injury prevention, supportive home environment,
sexual development and health, and adolescent risk-taking
behaviours (HEADDSS)].
Appropriately assesses and manages children and adolescents
presenting with common (key) conditions.
Able to diagnose and manage key pediatric mental health issues.
Provides appropriate advice and reassurance to parents regarding
common infectious diseases which do not routinely require medical
attention or antibiotic therapy.
Prescribes appropriate medications and dosages considering
patient age, weight and other parameters.
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Communicator
1*
2
3
4
5
NA
1*
2
3
4
5
NA
1*
2
3
4
5
NA
1*
2
3
4
5
NA
1*
2
3
4
5
NA
Optimizes the physical environment for patient comfort, privacy,
engagement and safety.
Utilizes patient centred interviewing skills and seeks corroborating
information as needed.
Adapts communication methods based on the age of the child.
Communicates the plan of care clearly and accurately to patients
and their families.
Answers questions from patients and families to facilitate decisionmaking.
Communicates in a clear and timely way across all domains
(charting, letters, reports) and mediums (oral, written, electronic).
Collaborator
Seeks and appropriately responds to feedback from colleagues in
the health professions.
Recognizes the role and scope of practice of other health
professionals.
Appropriately uses referral/consultations to support patient care.
Demonstrates safe handover of the care of patients to other health
care professionals.
Leader/Manager
Considers costs of diagnostic and therapeutic interventions.
Completes patient related paperwork effectively and in a timely
fashion.
Health Advocate
Identifies vulnerable or at-risk patients.
Seeks appropriate community-based resources for patients.
Scholar
Recognizes knowledge gaps and seeks appropriate resources to
address these gaps.
Integrates best available evidence into clinical decision-making.
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Professional
1*
2
3
4
5
NA
Demonstrates professional behaviour.
Demonstrates an approach to ethical issues encountered in
practice.
Attends to responsibilities and completes duties as required.
Recognizes his/her limitations and seeks assistance appropriately.
Is consistently available and responds in a timely fashion when on
call.
Demonstrates professional behaviour.
Entrustable Professional Activities (EPAs)
Please provide an opinion as to this resident’s ability to perform the following EPAs:
5: can supervise
others *
4:”unsupervised”
practice
3: practice with
supervision on
demand
2: practice with full
supervision
1: cannot practice
the EPA *
(Note: final decisions regarding ‘entrustability’ will be made by the program)
18. Provide family medicine centered care to
newborns in the first weeks of life.
19. Provide a periodic health exam and
preventative care of infants, children and
adolescents.
20. Assess, manage and follow-up infants,
children and adolescents presenting with
common (key) conditions.
* must provide comment when selecting
DATA SOURCES:
Number of field notes used for this evaluation: ____
Procedure log reviewed for this rotation: ___
OVERALL COMMENTS:
Please give examples and elaborate on strengths and areas for improvement identified.
* There MUST be a comment for any rating indicated by an asterisk
STRENGTHS:
AREAS FOR IMPROVEMENT:
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OVERALL ASSESSMENT OF RESIDENT’S PERFORMANCE
Major lapses and/or
multiple minor lapses
precluding independent
performance of goals
and objectives of this
rotation
Minor lapses but not
impairing overall safety
or patient outcomes
Consistently performs
the objectives
competently and safely
Frequently functions at a
level beyond that
described in the goals
and objectives and
expected of a successful
resident in this rotation
Fail
Routinely functions at a
level beyond that
described in the goals
and objectives and
expected of a successful
resident in this rotation
Borderline Pass
Pass
Vacation/Conference/Sick Time: ___________________
This assessment was completed by:
One individual (please name):
A group: (list members):
Other:
Name of rotation coordinator:
ITAR completed by:
ITAR discussed with resident by:
Date discussed:
Not discussed (state reason):
Resident’s comment:
I agree with this evaluation
I disagree with this evaluation
Resident’s signature: _____________________________ Date: __________
Any concerns about the above assessment should be addressed by completing the Request for Review of Assessment
Form available in the Program Office and returned by the resident within one week of the date of the evaluation.
Date reviewed by the Site Education Director:
Comments:
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