Child and family_final master_Layout 1 21/08/2013 10:09 Page 1
In Placement Multisource Feedback: Ask all clinicians completing an IPMSF to sign below.
1.
Clinician name
Job title
2.
Specialty
Paediatrics: Core
Signature
UCL MEDICAL SCHOOL
Paediatrics: General
3.
Child & Adolescent Mental Health
4.
Core General Practice
5.
GP Child Health
6.
Dermatology
7.
Year 5
8.
9.
10.
Supervised Learning Events (SLEs): A minimum of six is required, but you are encouraged to
do more to maximize the feedback you receive. Please indicate below the SLEs to show that you
have fulfilled the requirements, and indicate total completed.
SLE
Specific area of practice
CBD
Paediatrics (core or general)
CBD
Psychological aspect of child’s health
CBD
CBD
CEX
CEX
Assessor name
Date
Paediatrics (core or general)
2013-14
Firm (please circle)
A/B/C
Block (please circle) 1 / 2 / 3
Core general practice
By a paediatrician (core or general)
By a paediatrician (core or general)
Case Based Discussions (CBD)
Total completed in this module
Mini Clinical Evaluation Exercise (CEX)
Patient Pathway Contact dates: Ask patients to sign below
Date 1:
Date 2:
Patient to sign:
Patient to sign:
Explanations for any uncompleted items on card: Attach extra sheet if needed
Child & Family Health with
Dermatology
Record of Completed Procedures
Must be submitted at the end of the module.
Child and family_final master_Layout 1 21/08/2013 10:09 Page 3
Core procedures and competencies
Each procedure/competency (items 1-5) must be performed under supervision in a clinical
setting (ie. not in Clinical Skills Centre). Supervisors should only sign off a student if they
perform at a level equivalent of a FY1 doctor on the first day
1. Measure occipito-frontal head
circumference (OFC)
Signature
1
Name
1
Name
1
3. Plot weight, height & OFC on growth chart
Date
1
Signature
Name &
Designation
Date
4. Dermatology in general practice – Clinician signature and comments required for both
1
Signature
1
2
Name &
Designation
Module assignments To be signed off after successful completion
1. Practical prescribing in paediatrics:
To be signed off during Core Paediatrics
1
Name
& Designation
2. Core GP: Chronic care essay
Date e-mailed to GP
Course Administrator
1
Date
Date
Grade given by GP Tutor
2
3. Child and adolescent mental health
(CAMH)
Designation
& Designation
Date
2. Community paediatric clinic
(community paediatrician)
Name &
Name
Signature
Signature
Signature
& Designation
Date
1
Total number attended in module
Name
& Designation
Signature
Signature
1. General paediatrics clinic
Date
Date
5. Change or feed baby
To be signed by the supervising practitioner in charge of the clinic. If clinic not running,
contact the Undergraduate Administrator and record as appropriate (including date and name
of contact).
Name &
Designation
& Designation
Date
Signature
Signature
1
Name
& Designation
2. Test urine using dipstick
4. Accompanied paediatric doctor for
neonatal check
Clinic attendance
3. Basic life support – paediatrics
Signature
1
Name
& Designation
Date
4. Community Paediatrics: Presentation
Optional – if completed, record grade given.
Grade
Date
Comments by
clinician
Date
5. Dermatology hospital clinics – Clinician signature and comments required for both
Signature
Name &
Designation
Comments by
clinician
Date
1
2