Louisiana State University Health Science Center
School of Medicine, Department of Internal Medicine
Section of Physical Medicine & Rehabilitation
Fax: 504-897-7145
Peer Review Resident Evaluation Form
Resident’s Name _________________________
Evaluation Period _________________________
Evaluator’s Name _________________________
Rotation Name _________________________
PGY Level ______________________________
Evaluation Date ________________________
Evaluate the resident’s ability to carry out the following clinical tasks. Few individuals will merit a rating of either superior or very
poor. Most will receive an average rating. Use the following scale: 9 = Superior; 8 = Outstanding; 7 = Excellent; 6 = Above Average,
Exceeds Expectation; 5 = Average, Expected Level of Performance; 4 = Marginal, Approaching Expectations; 3 = Unsatisfactory,
Needs Attention; 2 = Poor, 1 = Very Poor.
1. Patient Care
Superb, accurate, comprehensive medical
interviews, physical examinations, review of
other data, and procedural skills; always makes
diagnostic and therapeutic decisions based on
available evidence, sound judgment and patient
preferences.
2. Medical Knowledge
Exceptional knowledge of basic and clinical
sciences; highly resourceful development of
knowledge; comprehensive understanding of
complex relationships and mechanisms of
disease.
Practice-Based Learning &
Improvement
Constantly evaluates own performance,
incorporates feedback into improvement
activities; effectively uses technology to
manage information for patient care and
self-improvement.
9 8 7 6 5 4 3 2 1
 Performance needs attention
 Insufficient contact to judge
Incomplete, inaccurate medical interviews,
physical examinations, and review of other
data; incompetent performance of essential
procedures; fails to analyze clinical data and
consider patient preferences when making
Medical decisions.
9 8 7 6 5 4 3 2 1
 Performance needs attention
 Insufficient contact to judge
Limited knowledge of basic and clinical
sciences; minimal interest in learning; does
not understand complex relations or
mechanisms of disease.
3.
Interpersonal and Communication
Skills
Establishes a highly effective therapeutic
relationship with patients and families;
demonstrates excellent relationship building
through listening, narrative and nonverbal
skills; excellent education and counseling of
patients, families, and colleagues; always
“interpersonally” engaged.
9 8 7 6 5 4 3 2 1
 Performance needs attention
 Insufficient contact to judge
Fails to perform self-evaluation; lacks
insight and initiative; resists or ignores
feedback; fails to use information
technology to enhance patient care or pursue
self-improvement.
4.
5. Professionalism
Always demonstrates respect, compassion,
integrity, honesty; teaches/role models
responsible behavior; total commitment to
self-assessment; willingly acknowledges
errors; always considers needs of patients,
families, and colleagues.
9 8 7 6 5 4 3 2 1
 Performance needs attention
 Insufficient contact to judge
Does not establish even minimally effective
therapeutic relationships with patients and
families; does not demonstrate ability to
build relationships through listening,
narrative or nonverbal skills; does not
provide education or counseling to patients,
families, or colleagues.
9 8 7 6 5 4 3 2 1
 Performance needs attention
 Insufficient contact to judge
Lacks respect, compassion, integrity,
honesty; disregards leads for selfassessment; fails to acknowledge errors;
does not consider needs of patients,
families, colleagues; does not display
responsible behavior.
6. Systems-Based Practice
Effectively accesses/utilizes out resources;
effectively uses systematic approaches to
reduce errors and improve patient care;
enthusiastically assists in developing
systems’ improvement.
7. Overall Clinical Competence
9 8 7 6 5 4 3 2 1
 Performance needs attention
 Insufficient contact to judge
Unable to access/mobilize outside resources;
actively resists efforts to improve systems of
care; does not use systematic approaches to
reduce error and improve patient care.
9 8 7 6 5 4 3 2 1
Outstanding overall clinical competence.
Very poor overall clinical competence.
 Performance needs attention
 Insufficient contact to judge
8. Physiatric Knowledge
9 8 7 6 5 4 3 2 1
Up-to-date, extensive, well integrated and applied
Self-motivated to acquire knowledge; recognizes
and responds to psychosocial aspects of illness
Limited, fragmented, poorly organized and
applied; insufficient motivation to acquire
knowledge; does not recognize or respond to
psychosocial aspects of illness.
 Performance needs attention
 Insufficient contact to judge
9.
Comments:
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Resident Signature _______________________
Attending Signature __________________________
Return to LSU PM&R Residency Office, Touro Infirmary, 1401 Foucher Street, Suite 10012, New Orleans, LA 70115.