Evaluation for Away-Rotations

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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

FINAL GRADE

COMMENTS:

3 = No Issues whatsoever 2 = Some concern about this issue 1 = definitely a problem

Professionalism

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

Return this form to:

Brody Student Affairs fentonj@ecu.edu

Fax-252-744-3250 or 600 Moye Blvd, Mail Stop 613, Greenville, NC 27834

Revised 2/2016

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