Mercy Catholic Medical Center Surgical Residency Program
Surgery Resident Evaluation Form (PGY II)
Resident:
Rotation: SURGICAL CRITICAL CARE (SICU)
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) Cardiovascular and pulmonary
physiology.
B) Surgical nutrition and fluid
electrolyte and use of blood
products.
C) Airway and vascular anatomy.
D) Pharmacology of cardiotonic and
vasoactive drugs, antibiotics,
analgesics, sedatives, etc.
Please place check in appropriate box:
Knowledgeable,
CLINICAL PERFORMANCE:
Confident, and
Effective
E) Able to perform and document a
comprehensive history and
physical exam.
F) Understands and appropriately
manages ventilators.
G) Understands and appropriately
manages hemodynamics.
H) Understands and appropriately
manages sepsis and infection.
Please place check in appropriate box:
Knowledgeable,
OPERATIVE ABILITIES:
Confident, and
Effective
I) Insert central line and PA catheter
J) Insert arterial catheter
K) Endotracheal intubation.
L) Places chest tubes.
M) Perform tracheostomy.
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
N) Recognize and treat hypovolemia
O) Recognize and treat systemic inflammatory response
syndrome.
P) Recognize and treat nosocomial pneumonia.
Q) Wean patient from ventilator.
R) Recognize and treat renal failure.
S) Recognize and treat acute psychosis.
T) Discuss treatment plan and expected outcome with
family.
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 Director, MCMC General Surgery
Residency Program, 1500 Lansdowne Avenue, Darby, PA, 19023.
Thank you for your assistance.
No