family practice residency program evaluation

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FAMILY PRACTICE RESIDENCY PROGRAM EVALUATION
GASTROENTEROLOGY
Please rate the physician named below in comparison to other family physicians with whom you have worked. Circle one
rating response per item. Circle the appropriate number between 1 and 5 where 1 is unable to pass and 5 is the highest rating.
If you have had insufficient contact to evaluate this physician on a particular characteristic, circle UE (Unable to Evaluate).
Name of Resident Physician
Rotation Dates
Name of Evaluator
Date ______________________
____________________________________________________________________________________________
RATING SCALE
1 = Unable to Pass*
2 = Learning
3 = Capable
4 = Proficient
5 = Mastery*
UE = Unable to Evaluate
* = Documentation Required
____________________________________________________________________________________________
1.
Is able to list the causes of and treatments for constipation
1
2.
UE
2
3
4
5
UE
2
3
4
5
UE
2
3
4
5
UE
2
3
4
5
UE
2
3
4
5
UE
2
3
4
5
UE
2
3
4
5
UE
Understands inflammatory disease of small and large bowel
1
11.
5
Understands causes and complications of biliary tract disease
1
10.
4
Can diagnose and treat pancreatic disease
1
9.
3
Understands indications and complications of colonic surgery
1
8.
2
Understands indications and complications of gastric and small bowel surgery
1
7.
UE
Understands the role of somatic dysfunction in GI disease
1
6.
5
Is knowledgeable about peptic ulcer disease
1
5.
4
Can diagnose and treat proctitis, anal and rectal pain
1
4.
3
Understands causes and diagnostic approach to diarrhea
1
3.
2
2
3
4
5
UE
5
UE
Can diagnose and manage hepatic disease
1
2
3
4
12.
Performs a thorough gastrointestinal history and physical exam
1
2
3
4
5
UE
Justification for 1 or 5_________________________________________________________________________
____________________________________________________________________________________________
Comments___________________________________________________________________________________
____________________________________________________________________________________________
_________________________________________________________
Evaluators Signature
_______________________________________________________________
Program Directors Signature
_______________________________________________________________
Resident Signature
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