Mercy Catholic Medical Center Surgical Residency Program
Surgery Resident Evaluation Form (PGY II)
Resident:
Rotation: PEDIATRIC SURGERY
Name of Evaluator:
Rotation Evaluation Dates:
Please evaluate the above resident on the basis of performance during this specific rotation. Rank each
resident on a 1-5 scale with 5 being the highest. In general, a “1” would be unsatisfactory, the average
resident is a “3”. If there is inadequate information, please check “not applicable”.
General:
Evaluation (1-5):
Not Applicable:
1.
2.
3.
4.
5.
Initiative, self-motivated.
Dependability, can be counted on to complete tasks.
Interacts well with patient and staff.
Self-confident but will seek help from others.
Teaching of medical students.
Please place check in appropriate box:
Knowledgeable
COGNITIVE KNOWLEDGE:
Demonstrates understanding of the
basic science foundation of the
specialty
Knowledgeable
Learning But
Inadequate
Absent or
Inadequate
Knowledgeable,
But Not
Independent
Learning But
Below
Expectations
Unsatisfactory
Knowledgeable,
But Not
Independent
Learning But
Below
Expectations
Unsatisfactory
and Able To
Teach
A) Physiology, fluid and electrolytes,
nutrition, pulmonary function and
hemodynamics of children.
B) Pathology of pediatric disease.
C) Pediatric anatomy.
D) Special pharmacology aspects of
pediatrics.
Please place check in appropriate box:
Knowledgeable,
CLINICAL PERFORMANCE:
Confident, and
Effective
E) Able to perform a comprehensive
history and physical exam, develop
comprehensive plan.
F) Able to provide and direct pre- and
post-operative care for pediatric
surgical patients.
G) Appropriately diagnose and treat
surgical complications.
H) Handle urgent and emergent life
threatening medical and surgical
conditions in children.
Please place check in appropriate box:
Knowledgeable,
OPERATIVE ABILITIES:
Confident, and
Effective
I) Understands the function of surgical
instruments in pediatric patients.
J) Able to tie knots effectively and
rapidly in poorly accessible areas.
K) Understands principles of pediatric
surgical exposure.
L) Uses scalpel, forceps, scissors,
and laparoscopic equipment
effectively.
Please place check in appropriate box:
Knowledgeable,
OPERATIVE ABILITIES:
Confident, and
Effective
Knowledgeable,
But Not
Independent
Learning But
Below
Expectations
Unsatisfactory
N) Able to control bleeding in poorly
accessible areas.
Based on the experience in this rotation do you think the resident would be able to:
Please place check in appropriate box:
Independent,
Confident,
Effective, and
Safe
Needs
Direction
Needs
Much
Assistance
O) Diagnose and perform an appendectomy for
perforated appendicitis.
P) Diagnose and perform an inguinal herniorrhaphy.
Q) Insert a chest tube.
R) Appropriately discuss a problem with the pediatrician
and pediatric nurse.
S) Diagnose pyloric stenosis and prepare patient for
surgery, including fluid and electrolyte management.
T) Discuss management plan and outcome with parents.
Please place check in appropriate box:
Overall Evaluation (Compare with the last 10 resident at this level on this rotation):
Top 20%
Middle 60%
Lower 20%
Comments (required):
Do you think this resident should be advanced to the next clinical year?
Yes
No
Needs more
evaluation
Signed:
Date:
Please return the completed form to Program Director, MCMC General Surgery
Residency Program,1500 Lansdowne Avenue, Darby, PA, 19023.
Thank you for your assistance.
No