Pediatric Respiratory Medicine
Subspecialty Resident Self-Assessment Form
Name: ______________________________________
Date: ______________________
Please rate the degree to which you agree with the following statements:
(1 – strongly disagree
3 – neutral
5 – strongly agree)
COMMUNICATOR:
1. I communicate effectively with patients
1
2
3
4
5
2. I communicate effectively with patients’ families 1
2
3
4
5
3. I communicate effectively with other health
Professionals
1
2
3
4
5
4. I communicate treatment options to patients
1
2
3
4
5
5. I maintain quality medical records
1
2
3
4
5
6. I collaborate with physician colleagues
1
2
3
4
5
7. I participate effectively as a member of the
health care team
1
2
3
4
5
8. I handle transfer of care appropriately
1
2
3
4
5
9. I provide a clear understanding about who is
responsible for the continuing care of patients
1
2
3
4
5
10. I manage health care resources efficiently
1
2
3
4
5
11. I co-ordinate care effectively for patients with
other health professional and physicians
1
2
3
4
5
COLLABORATOR:
MANAGER:
HEALTH ADVOCATE:
12. I recognize psychosocial aspects of illness
1
2
3
4
5
13. I critically evaluate the medical literature to
optimize clinical decision making
1
2
3
4
5
14. I facilitate the learning of medical colleagues
and co-workers
1
2
3
4
5
15. I respect the rights of patients
1
2
3
4
5
16. I show compassion for patients and their
families
1
2
3
4
5
17. I maintain confidentiality of patients and their
families
1
2
3
4
5
18. I accept responsibility for my professional
actions
1
2
3
4
5
19. I manage my stress effectively
1
2
3
4
5
20. I recognize my limitations
1
2
3
4
5
21. I assume appropriate responsibility for patients 1
2
3
4
5
22. I provide timely information to referring
physicians
1
2
3
4
5
23. I exhibit professional and ethical behaviour
1
2
3
4
5
24. I perform technical procedures skillfully
1
2
3
4
5
25. I select diagnostic test appropriately
1
2
3
4
5
26. I critically assess diagnostic information
1
2
3
4
5
SCHOLAR:
PROFESSIONAL:
MEDICAL EXPERT:
27. I make the correct diagnosis following
consultation
1
2
3
4
5
28. I select appropriate treatments
1
2
3
4
5
Please identify areas/skills you feel are your greatest strengths, as well as those you most
wish to improve.
Strengths:
Areas for improvement: