Student Global Assessment Form – OB-GYN
Completed by Clerkship Director & OB-GYN Education Committee
Student:
History & Physical (check one)
 History & PE is
 Obtains basic data,
 History & PE
incomplete or
but needs work on
relatively complete
inaccurate. Important organization PE missing
and accurate with
data not obtained.
some essential elements. satisfactory
organization.
 Comprehensive,
thorough, and precise
history. PE complete
and significance
understood.
 H&P exceptionally
complete. Importance of
findings apparent.
 Unable
to assess
 Sound, logical
thinker, considers all
factors to reach
accurate decision.
Above average use of
lab data and very sound
clinical judgment.
 Evaluates data
critically and consistently
arrives at correct
decisions even of highly
complex nature.
Outstanding clinical
judgment.
 Unable
to assess
 Always analyzes
critically and synthesizes
new information. Always
deals with events at a
conceptual level.
 Unable
to assess
 Outstanding
knowledge of basic
medical principles
relating to patients'
problems, both common
and uncommon.
Demonstrated extensive
reading about patient’s
problems.
 Unable
to assess
 Exceptionally good
technical skills. Rapidly
acquired news skills.
 Unable
to assess
 Clear, organized,
accurate, complete,
polished presentations
and notes. Clearly
delineates a differential
diagnosis.
 Unable
to assess
 Can always be
counted on for
attendance and
punctuality in patient
care responsibilities.
Believable without
reservation.
 Unable
to assess
Data Analysis (check one)
 Great difficulty
integrating and
interpreting history, PE,
and lab data to reach
diagnosis or
management decisions.
Critical analysis/Clinical
 Rarely analyzes
critically. Cannot
synthesize new
information or deal with
events at conceptual
level.
 Minimal ability to
evaluate data from
history, PE, and lab.
Reaches erroneous
conclusions.
 Able to integrate
information to form
reasonable diagnostic
possibilities. Good
use of lab data and
clinical judgment.
Judgment (check one)
 Can sometimes
 Can usually
 Almost always
analyze critically &
analyze critically and
analyzes critically and
synthesize new
synthesize new
synthesizes new
information. Has
information. Can
information. Almost
occasional difficulty in
usually deal with
always deals with events
dealing with events at a events at a conceptual at a conceptual level.
conceptual level
level.
Medical Knowledge (check one)
 (Principles,
 Medical knowledge
 Adequate
 Above average
pathophysiology) clearly is marginal. Information comprehension of
knowledge of disease
below acceptable
base is adequate in some basic pathophysioand pathological
standards Lacks
areas but deficits exist logical principles and
processes with notable
knowledge to deal with
in important clinical
application to
ability to apply them to
common clinical
problems. Very little
patients' problems.
the patients problems.
problems. Did not
evidence of outside
Kept up with reading
Demonstrated evidence
demonstrate evidence
reading.
and learning on the
of outside reading and
of outside reading.
rotation.
studying.
Technical skills (check one)
 Technical skills do
 Acceptable skills
 Good skills
 Very good technical
not meet minimum
development. Could
development. Can
skills. Learns quickly and
expectations.
complete all required
learn new skills easily can perform with
procedures with help.
with instruction.
minimal supervision.
Information Management (Presentation Skills & Progress Notes) (check one)
 Presentation and
 Presentation and
 Presentations and  Presentations and
notes too often
notes have notable gaps notes have a
notes thorough & well
incomplete,
in clarity, organization,
satisfactory
organized, concise and
disorganized, inaccurate completeness and
description of patient accurate. Above average.
or lacking in detail.
accuracy. Often fails to that is adequately
integrate data
accurate, complete,
appropriately.
and organized.
Dependability (check one)
 Cannot be relied
 Usually present but  Can usually be
 Can almost always
upon. Attendance and
sometimes tardy or
relied upon, but is
be relied upon. Is
punctuality are usually
sporadic in attendance
occasionally absent or almost never absent or
erratic. Cannot be
without good
late without justified late except for justified
believed
justification.
reasons. Usually
reasons. Is honest and
Occasionally believable
honest and believable. believable.
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Patient Interaction (check one)
 Avoids personal
 Deficient in
contact with patients
grasping and dealing
and families. Tactless
with emotional and
and inattentive to
personal needs of
patient needs. Shows
patients and their
little awareness of
families and has
patient's personal and
difficulty gaining
emotional problems.
cooperation.
Mistrusted by pts.
Cooperation (check one)
 Generally does
 Behavior usually
not cooperate with
accept-able to
other health
colleagues with some
professionals and/or
exceptions. Makes little
acts in ways conveying
impression. Cooperates
lack of respect for
when necessary
others professional
roles.
 Able to
understand and deal
with emotional and
personal needs of
patients and families
and can enlist their
cooperation.
 Listens and
communicates well with
patients and families and
gains most patients'
confidence and
cooperation.
 Unusually sensitive
and skillful in eliciting
and dealing with
emotional and personal
problems of patients and
families. Establishes
rapport. Wins
confidence & cooperation
of pts.
 Unable
to assess
 Maintains
acceptable and
workable co-worker
relationships.
 Active member of
team. Elicits cooperation
of others and
establishes atmosphere
of mutual respect and
dignity with coworkers.
 Elicits and
contributes to full
cooperation among health
professionals.
Exceptionally active
member of team.
 Unable
to assess
Near Honors
Honors
Summary Evaluation: (check one)
Marginal Pass
Pass
High Pass
Overall Grade: __________________
Areas of strength:
Areas in need of improvement:
Would you recommend this student for a residency position in your program? Yes ____
No _____
Rater’s Signature __________________________
Date: _______________
Student’s Signature __________________________
Date: _______________
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