MEDICAL STUDENT CLINICAL EVALUATION FORM
DUKE UNIVERSITY SCHOOL OF MEDICINE
COURSE NAME & NUMBER: SURGERY 205C
STUDENTS NAME: __________________________________________________________________________________
COURSE WEIGHT:
08.0
DATES of rotation: ____________________
Name of Evaluator: _____________________________
Rotation:
Scoring (1)
(2)
(3)
Application of Basic Science Fund of Knowledge to Clinical Setting
___ Poor fund of knowledge;
___ Limited fund of knowledge; can
___ Solid fund of knowledge;
limited ability to apply
apply clinically: has potential for
applies readily to clinical
clinically.
improvement.
problems.
(4)
___ Outstanding fund of
knowledge, superior, advanced
skills applying to complex
problems.
Interviewing Skills (check if evaluation is from ___ direct observation and presentations or presentations alone)
___Disorganized, incomplete,
___Organized, obtains basic history
___Organized, usually complete ___Excellent skills; thorough yet
lacks focus.
but points often missed including
including pertinent (+) & (-)
succinct and focused history.
pertinent (+) & (-) ROS.
ROS; but often with extraneous
information.
Physical Examination Skills (check if evaluation is from ___ direct observation and presentations or presentations alone)
___Omits critical parts of the
___Generally complete but often misses ___Complete; usually
___Thorough and accurate;
exam and/or deficient exam
significant abnormal findings.
recognizes abnormal findings.
focused relative to the history
skills.
Presentation Skills (Formal presentations and during rounds/clinic)
___Disorganized/incomplete;
___Generally complete; may lack
by end, listeners uncertain of
organization/fail to highlight abnormal
primary clinical problem/recent
findings; needs much assistance.
events.
Improvement during
period of observation.
___Y
___N
___N/A
___Y
___N
___N/A
___Y
___N
___N/A
___Presentations organized,
logical; highlights abnormal
findings; preparation requires
some assistance.
___Consistently organized, logical,
complete; preparation does not
require assistance.
___Y
___N
___N/A
___Formulates assessment of
major problem; may have
trouble identifying/prioritizing
multiple problems.
___Consistently able to formulate
assessment of basic problems;
also can prioritize multiple
problems.
___Y
___N
___N/A
Ward/Clinic/Other Assigned Duties (orders, follow-up of tests)
___Not regularly involved in
___Involved in ward/clinic duties but
ward/clinic management.
usually passive; follows direction of
others.
___Active team member;
takes significant responsibility
for patient management.
___Takes patient responsibility;
comfortably evaluates/manages
multiple patients.
___Y
___N
___N/A
Record Keeping (Initial Work Up, Interval/Progress Notes)
___Incomplete or erroneous.
___Includes basic information; rarely
analyzes new data/impact on patient
management.
___Accurate data included
with ongoing assessments of
basic problems.
___Accurate, thorough, and
succinct (intern level)
___Y
___N
___N/A
Assessment, Formulation and Clinical Application Skills
___Usually unable to formulate ___Usually handles major problem; may
an assessment of basic
not integrate all aspects (H&P, labs, rx);
medical problems.
suggests elemental understanding.
Please return to Honor Gifford (honor.gifford@duke.edu) or fax to 919-613-5902. Thank you!
Scoring (1)
Dependability
___ Unreliable, often absent or
late; commitment uncertain
Response to feedback
___No insight to weaknesses;
rejects feedback, no behavior
changes.
Interaction with patients
___Insensitive to needs,
feelings, values of patients.
(2)
PROFESSIONAL
ATTRIBUTES
(4)
(3)
Improvement during period
of observation.
___ Fulfills basic responsibilities; little
dedication or commitment to patient
care.
___ Dependable team player
and deliverer of patient care.
___ Dependable; highly
committed to and enjoys clinical
care.
___Y
___N
___N/A
___Defensive response but does lead to
change.
___Mature response to
feedback; strives for
improvement
___Mature response; regularly
seeks feedback and ways to
improve.
___Y
___N
___N/A
___Often uncomfortable in patient
interactions.
___Interacts well with patients
and families.
___Extremely compassionate and
respectful with patients/families.
___Y
___N
___N/A
___Interacts well with other
health care team members.
___Interacts well; seeks
contributions of others on the
health care team.
___Y
___N
___N/A
___Y
___N
___N/A
___Y
___N
___N/A
Interactions with other members of health care team
___Avoids interactions; little
___Occasional difficulty interacting with
respect for contributions of
others.
others.
Other (Course instructors’
criteria)
House Staff Potential
___Excellent
___Good
___Satisfactory
___ Unsatisfactory
Comments: (Please specify how grade was determined, including any test scores, and justification for all honors grades.)
Suggestions for improvement: (not to be included in Dean’s letter for recommendation)
SIGNATURE:__________________________________________________
DATE:_____________
This document contains confidential peer review information to be used in the assessment of the quality of the delivery of healthcare.
This document and the information in it are CONFIDENTIAL and should not be distributed outside the relevant review committees
Please return to Honor Gifford (honor.gifford@duke.edu) or fax to 919-613-5902. Thank you!