Women's health_final master_Layout 1 21/08/2013 12:01 Page 1
In Placement Multisource Feedback: Ask all clinicians completing an IPMSF to sign below
1.
Clinician name
Job title
2.
Specialty
Obstetrics/Gynaecology
Signature
UCL MEDICAL SCHOOL
Obstetrics/Gynaecology
3.
Midwifery
4.
Genito-urinary medicine
5.
Genito-urinary medicine
6.
Breast
7.
Year 5
Urology
8.
9.
10.
Supervised Learning Events (SLEs): A minimum of seven is required, but you are encouraged
to do more to maximise the feedback you receive. Please indicate below the SLEs to show that
you have fulfilled the requirements, and indicate total completed.
SLE
CEX
Specific area of practice
Sexual history taking
Female genital exam: bimanual
CEX
examination +/- Cusco speculum
CEX
Attendance of woman in labour
CEX
Antenatal assessment & examination
CBD
Any O&G or GUM topic
CBD
Any Breast Health case
CBD or CEX Any Urology case
Case Based Discussions (CBD)
Mini Clinical Evaluation Exercise (CEX)
Assessor name
Date
2013-14
Firm (please circle)
A/B/C
Block (please circle) 1 / 2 / 3
Total completed in this module
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
Women’s Health & Men’s Health
Record of Completed Procedures
Must be submitted at the end of the module.
Women's health_final master_Layout 1 21/08/2013 12:01 Page 3
Core procedures and competencies
Each procedure/competency (items 1-10) must be performed under supervision in a clinical
setting (i.e. not in Clinical Skills Centre or Gynaecology Teaching Associate session).
Supervisors should only sign off a student if they perform at a level equivalent of a FY1
doctor on the first day.
1. Cusco speculum examination
Signature
Name & Designation
Date
2. Female bimanual examination
Signature
Name & Designation
Date
3. Antenatal examination
Signature
Name & Designation
Date
4. Male genital examination
Signature
Name & Designation
Date
5. Male catheterisation
Signature
Name & Designation
Date
Labour and deliveries
(a) Normal vaginal deliveries observed
Home site
Signature
6. Cervical smear
Signature
Name & Designation
Date
7. Female urethral catheterisation
Signature
Name & Designation
Date
8. Urine pregnancy testing
Signature
Name & Designation
Date
Signature
Date
10. Digital rectal examination of prostate
Signature
Name & Designation
Date
Gynaecology teaching associate (GTA) session
Date
Home or DGH (circle)
Date
Total number performed in module:
Total number of instrumental deliveries observed in module:
Total number of caesarean sections observed in module:
DGH
Signature
To be signed by the supervising practitioner in charge. If session not running,
contact the Undergraduate Administrator and record as appropriate (including date
and name of contact).
Antenatal clinic 1 Antenatal clinic 2
Breast clinic
Breast theatre
Breast MDT
Name &
Designation
Date
2. Urology clinical sessions
Prostate
clinic
Haematuria
clinic or flexible
cystoscopy list
Andrology
clinic
Robotic
theatre list
Urology
theatre list
Urology
ward teaching
Name &
Designation
Date
3. HIV ward teaching (clinician to also complete feedback form)
Date
Name & Designation
Name & Designation
Clinic and ward attendance
Signature
Signature
Home or DGH (circle)
Date
Total number attended in module:
Signature
Name & Designation
(b) Normal vaginal deliveries performed (one at each site)
Home site
DGH
Signature
1. Women’s Health (including breast) sessions
9. Breast examination
DGH
Home site
Outcome of
labour
Name & Designation
Name & Designation
(c) Assisted deliveries observed
(d) Labours attended (full or partial attendance)
Signature
HIV on call
HIV testing on ward
HIV ward teaching 1
HIV ward teaching 2
Name &
Designation
Date
4. GU clinics (clinician to also complete feedback form)
Signature
Name &
Designation
Date
GUM 1
GUM 2
GUM 3
Health advisor
HIV clinic
Family
planning