Procedural Skills
Physical examination
Brody School of Medicine
– M4 Medical Student Evaluation Form
Student’s Name
Course Title
Course Number
Course Date
Course Director
Institution/Location
H: Exceptional; A: Above expectations; B: Meets expectations; C: Below expectations; F: Unacceptable; I: Extension approved by Course Director
If you circle C or F please provide specific comments in the spaces provided
Skill or Behavior (Circle One) Optimal Performance
Patient Care
History-taking
Care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health
H A B C F Identifies, pursues, and characterizes all problems in reasonable time; records are logically developed, cogent, organized, and of appropriate length
H A B C F Demonstrates proficiency in procedures appropriate to rotation, including use of equipment. Demonstrates a patientcentered approach, reflecting respect for patient privacy, comfort and safety
H A B C F Technically competent; suitably thorough; reasonable time; findings related to problems; record orderly and detailed
Clinical sources H A B C F Obtains, records, and uses all available information from clinical sources; interprets in relation to patient's problems
Medical Knowledge Knowledge of established and evolving biomedical, clinical, and cognate sciences and the application of this knowledge to patient care
Amount of Factual Knowledge H A B C F Demonstrates mastery of facts and concepts appropriate to the rotation. Employs knowledge fund to develop and support the differential diagnosis, identified gaps in personal knowledge fund and works to remedy them
Differential diagnosis H A B C F Groups all patient problems into reasoned differential diagnosis; rationale & plan to confirm diagnoses regularly demonstrate knowledge of pathophysiology
Treatment program
Practice-Based Learning & Improvement
H A B C F Identifies current & past treatment and potential drug allergies; formulates appropriate treatment plan; shows sound knowledge of pharmacology; recognizes need for urgent treatment and initiates appropriate action
Investigation and evaluation of their own patient care, appraisal and assimilation of scientific evidence, and improvements in patient care
Academic sources
Follow patient's progress
Interpersonal & Communication Skills
Verbal reports
H A B C F Extensively uses academic sources, including journals to study patient's specific problems; findings communicated and used to make clinical decisions
H A B C F Continuously monitors patient; reviews all clinical data; reassesses need for additional information or management, including rationales; follows through appropriately
Effective information exchange and teaming with patients, their families, and other health professionals
H A B C F Communicates clearly and succinctly; information complete, organized, synthesized, & includes rationale
Doctor-patient relationship
Systems-Based Practice
Efficacy, quality and safety
H A B C F Reassuring, caring, supportive, and accurate; relationships with patients engender confidence; communications with patients are effective, efficient, and educational
Actions that demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to call effectively on system resources to provide care that is of optimal value
H A B C F Selects therapies and interventions with costs in mind; identifies patients with limited resources for appropriate assistance; recognizes system-wide implementation of best practice (quality) and elimination of medical errors (safety) and opportunities for implementation of such policies
3 = No Issues whatsoever 2 = Some concern about this issue 1 = definitely a problem
A commitment to carrying out professional responsibilities, adhering to ethical principles, and showing sensitivity to a diverse patient population
Integrity and Trustworthiness
Compassion and Respect for Others
Teamwork & Professional Demeanor
Responsibility & Sense of Duty
Accountability & Initiative
Scholarship & Commitment to Learning
Concern for the Welfare of Patients
Self-Care & Self-Growth
3 2 1 Unable to rate
3 2 1 Unable to rate
3 2 1 Unable to rate
3 2 1 Unable to rate
3 2 1 Unable to rate
3 2 1 Unable to rate
3 2 1 Unable to rate
3 2 1 Unable to rate
Displays honesty and forthrightness; adheres to ethical standards; truthful in all communications; maintains confidentiality; reports inappropriate behavior by colleagues
Considerate; cooperative; displays empathy; respectful of different socioeconomic backgrounds & cultural traditions; sensitive; respects authority
Works well with others; maintains composure in difficult circumstances; inspires trust; avoids inappropriate remarks, adheres to local dress codes
Completes assigned duties; sets and achieves realistic goals; follows policies; responds promptly when called; detail-oriented; places patient needs first
Flexible; delegates effectively; accepts personal responsibility for mistakes; asks for help when needed; discloses medical errors when appropriate
Punctual; attends classes, clinics, other required events; seeks additional knowledge & skills; seeks feedback; willing to assist other learners
Treats patients and families with dignity; respects patient privacy; maintains accurate information in patient records; advocates for patients
Maintains personal health and hygiene; seeks advice, counsel, or tutoring when needed; avoids harmful behaviors
Course Director
’s Name: Signature : Date
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Revised 2/2016