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In Placement Multisource Feedback: Ask all clinicians completing an IPMSF to sign below
1.
Clinician name
Job title
2.
Specialty
Psychiatry
Signature
Psychiatry
3.
Health of Older Person
4.
Health of Older Person
5.
Cancer
6.
Ophthalmology
7.
Year 5
ENT
8.
GP
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
CEX
CBD
CBD
CBD
CBD
CBD or CEX
Specific area of practice
Fundoscopy
Otoscopy
Health of the Older Person case
Cancer case
Psychiatry case
Breaking bad news case
Student choice
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:
UCL MEDICAL SCHOOL
Patient to sign:
Patient to sign:
Explanations for any uncompleted items on card: Attach extra sheet if needed
HOPE: Health of the Older
Person, Ophthalmology,
Oncology, Psychiatry and ENT
Record of Completed Procedures
Must be submitted at the end of the module.
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Core procedures and competencies
Each procedure/competency (items 1-6) must be performed under supervision in a clinical
setting (i.e. 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. Health of the older person: Attend four small group or one to one ward teaching sessions.
Two in which you present a case and two in which you will perform an examination.
(a) Patient of interest case presentation
Details of
case:
e.g. fall
1
2
(b) Observed patient examinations
Details of
case:
e.g. fall
1
2
Date
Date
2. Ophthalmology: Perform three observed visual acuity & field tests plus two fundoscopy
Signature
Acuity & Field
Acuity & Field
Acuity & Field
Fundoscopy
Fundoscopy
Date
3. Psychiatry: Full psychiatric mental state examination for specific presentations
Signature
Name &
Designation
(b) Patient with affective symptoms
Signature
Name &
Designation
4. Palliative Care: two ½ day sessions
Date
Signature
Clinic & Theatre attendance
Signature
1
2
3
Date
(d) Patient with anxiety symptoms
Signature
Hospice
Seminar
Date
Date
Theatre attendance
Name &
Designation
Date
Signature
1
2
3
Name &
Designation
Module assignments
5. ENT: Observed neck examination
Name &
Designation
Signature
Clinic attendance
Date
Date
Signature
Theatre attendance
Name &
Designation
3. Oncology clinics – three clinics in total
Name &
Designation
Date
Name &
Designation
(c) Patient with cognitive impairment inc MMSE
Name &
Designation
Date
Signature
Date
2. ENT clinics: three clinics & three theatre attendances
Name &
Designation
(a) Patient of interest case presentation
Case presentation
Name &
Designation
1. Ophthalmology clinics: three clinics & one theatre attendance
Name &
Designation
Name &
Designation
Signature
Bedside teaching
Bedside teaching
To be signed by the supervising practitioner in charge. If clinic not running, contact the
Undergraduate Administrator and record as appropriate (including date and name of contact).
Signature
Signature
6. Oncology: Attend two bedside teaching sessions & present one patient you have clerked.
Neck examination
To be signed by an appropriate supervisor working in the specialty chosen by the student as the
focus of the assignment.
Polypharmacy
1. Practical prescribing project
Signature
Name &
Designation
Date