FAMILY PRACTICE RESIDENCY PROGRAM EVALUATION
REHABILITATION MEDICINE
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.
Demonstrates ability to obtain an accurate functional assessment and medical history of the rehabilitative patient
1
2.
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
5
UE
4
2
3
4
5
UE
Demonstrates the judicious use of properly applied osteopathic manipulative therapy
1
14.
3
Understands and can assess communication disorders
1
13.
2
Understands and can assess chronic pain
1
12.
UE
Understands and can assess amputee
1
11.
5
Understands and can assess spasticity
1
10.
4
Understands and can assess scoliosis
1
9.
3
Understands and can assess arthroplasty
1
8.
2
Recognizes and can assess neuromuscular diseases
1
7.
UE
Recognizes and can assess joint disorders
1
6.
5
Recognizes and can assess spinal cord trauma
1
5.
4
Recognizes and can assess central nervous system damage
1
4.
3
Performs a complete physical and osteopathic structural examination of the rehabilitative patient
1
3.
2
2
3
4
5
UE
Understands pharmacology as it applies to the rehabilitative patient and is integrated with the restorative process
1
15.
3
4
5
UE
Appreciates the role of occupational and physical therapy in the care plan for a rehab patient
1
16.
2
2
3
4
5
UE
Understands how to order and fit prosthetic devices
1
2
3
4
5
UE
Justification for 1 or 5_________________________________________________________________________
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Comments___________________________________________________________________________________
____________________________________________________________________________________________
_________________________________________________________
Evaluators Signature
_______________________________________________________________
Program Directors Signature
_______________________________________________________________
Resident Signature