FAMILY PRACTICE RESIDENCY PROGRAM EVALUATION
OBSTETRICS AND GYNECOLOGY
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.
2.
Understands the physiology of menstruation
1
2
3
4
5
Demonstrates knowledge of reproductive and urinary tract infections
1
3.
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
2
3
4
5
UE
2
3
4
5
UE
5
UE
5
UE
Understands geriatric urogenital problems.
1
14.
UE
Demonstrates thorough understanding of antepartum and postpartum care
1
13.
5
Distinguishes between benign and malignant neoplasm’s of the female reproductive tract
1
12.
4
Demonstrates knowledge of the legal parameters for conducting rape exam
1
11.
3
Understands the psychological and physical results of sexual assault
1
10.
2
Diagnoses and identifies treatment options for abnormal uterine bleeding
1
9.
UE
Demonstrates knowledge of maternal and perinatal health regional resource network
1
8.
5
Performs comprehensive adult female reproductive examination
1
7.
4
Understands family planning and fertility problems
1
6.
3
Demonstrates ability to perform neonatal resuscitation
1
5.
2
Demonstrates ability to manage abnormal Pap smear
1
4.
UE
2
3
4
Identifies pregnancy risk assessment systems
1
2
3
4
15.
Understands fetal monitoring
1
16.
4
5
UE
2
3
4
5
UE
Appropriately utilizes risk assessment protocols
1
18.
3
Can perform third degree perineal repair
1
17.
2
2
3
4
5
UE
Demonstrates awareness of the benefits of genetic counseling
1
2
3
4
5
UE
Justification for 1 or 5_________________________________________________________________________
____________________________________________________________________________________________
Comments___________________________________________________________________________________
____________________________________________________________________________________________
_________________________________________________________
Evaluators Signature
_______________________________________________________________
Program Directors Signature
_______________________________________________________________
Resident Signature