Universal Clerkship Evaluation Grading Form
Xth clerkship -Class of 201X
Student Name: __________
Evaluator:
Dr. Gussman
Date: _____________
Not observed.
COMPETENCY1A: PATIENT CARE
Students must be prepared to provide patient care that is compassionate, appropriate, and effective
HISTORY AND PHYSICAL EXAM
Often incomplete or
Usually complete and accurate
Complete & accurate. Histories well
Comprehensive information; thorough
inaccurate histories. Very
but occasionally important
organized and comprehensive.
& precise; questioning identifies subtle
poor interviewing skills.
information is missing. May be
Physical exam is complete, properly
problem areas. Excellent interview
Exam is incomplete; major
verbose. Exam is generally
sequenced, and reliable. Good exam
skills. Physical exam thorough,
deficiencies in technique.
complete; occasionally fails to
skills; identifies relevant findings;
technically sound & efficient. Elicits
Examination technique is
follow obvious leads; minor
follows up on important areas;
subtle findings; careful attention to
grossly inaccurate. Makes no deficiencies in technical skill.
technically sound. Sensitive to patient
clinical findings; anticipates patient
effort to put patient at ease.
Makes attempt to put patient at
needs for comfort and privacy.
needs for comfort and privacy.
ease.
3
4
5
Not
observed.
Frequently overlooks basic
tests; difficulty interpreting
results; unable to formulate a
treatment plan; decisions
risky and/or not costeffective.
Not
observed.
3
4
6
7
8
9
1B.DIAGNOSTIC TESTS & THERAPEUTIC PLANS
Understands basic tests & their
Has complete & efficient plan for
interpretation; decisions usually
diagnostic tests & consultation;
safe; may not be cost-effective.
interprets results correctly;
therapeutic program complete & safe;
uses common sense.
5
6
7
8
10
Efficiently modifies diagnostic strategy
as results are received; therapeutic
program comprehensive, thorough,
precise, cost-effective. Mature
decisions based on sound integration
of data & reasoning.
9
10
Rarely raises prevention and
health maintenance issues.
1C.DISEASE PREVENTION/ROUTINE HEALTH MAINTENANCE
Acknowledges importance of
Often integrates prevention and
prevention and health
health maintenance principles and
maintenance issues.
practices into health care plan.
Always integrates prevention and
health maintenance principles and
practices into health care plan.
3
5
9
4
6
7
8
10
Not
Observed.
1D. PROCEDURAL SKILLS
Difficulty using proper technique;
awkward with equipment or
bypasses accepted steps; timing,
coordination and/or organization
are faulty. Technique places
self/patient at risk.
Some difficulty using proper technique;
sometimes fails to organize equipment
before procedure; occasional problems
with timing or coordination.
Uses proper techniques; organizes Timing is precise; procedures
equipment before procedure;
performed with ease and dexterity. Able
timing is smooth; coordinated
to put patient at ease.
conduct of procedures.
3
5
7
4
6
8
9
10
Not
Observed
COMPETENCY 2A: MEDICAL KNOWLEDGE
Students must demonstrate knowledge about established and evolving basic and clinical biomedical sciences, including epidemiology and
social/behavioral sciences, and their application of this knowledge to patient care.
Poor recall of basic science,
Has basic knowledge of disease
Above average knowledge relevant to
Superior knowledge with mature
pathophysiology & clinical
processes & pathologic events; some
assigned patients; able to correlate
application to clinical setting;
information; cannot relate it to
ability to relate information to clinical
this knowledge consistently with
able to evaluate/apply recent
cases.
material.
clinical material.
literature.
Not Observed
3
4
Unable to integrate
elements of a clinical
knowledge base; has only
rudimentary problemsolving ability. Cannot
generate problem list or
differential diagnosis.
3
4
5
6
7
8
9
2B DIFFERENTIAL DIAGNOSES/ PROBLEM SOLVING
Somewhat awkward in integrating
Able to synthesize many aspects of
elements of a clinical knowledge base.
the clinical knowledge base into a
Can generate short list of appropriate
differential diagnosis and plan that is
differential diagnoses for assigned
supported by basic evidence-based
patients.
standards.
5
6
7
COMPETENCY 3: PRACTICE BASED LEARNING AND IMPROVEMENT
8
10
Produces sophisticated
differential diagnoses and plans;
synthesizes patient's problems
according to priority.. Diagnostic
reasoning and testing strategies
are astute.
9
10
Not observed.
Not observed.
Students must be able to engage in self-evaluation regarding their academic & clinical performance,
develop plans for personal improvement, and recognize how the application of new learning
can be used to improve patient care.
Little evidence of assigned or
supplemental reading. Cannot
accept constructive criticism. Fails
to share knowledge with others.
Completes reading and study
assignments. Accepts feedback when
offered. Takes responsibility for own
actions. Will offer information when
solicited.
Does some supplemental as well as
assigned reading. Actively solicits and
incorporates feedback. Volunteers
information with peers.
Self-motivated to expand
knowledge; intellectually curious.
Seeks advice and consultation
when needed. Is self-reflective.
Takes active role in sharing
information with peers. Contributes
to teaching efforts on the service
3
5
7
9
4
6
8
10
COMPETENCY 4: INTERPERSONAL AND COMMUNICATION SKILLS
Students must be able to demonstrate interpersonal & communication skills, both verbal and written,
that results in effective information exchange with patients, patients’ families, peers, and other health professions colleagues
Student communicates poorly
Student utilizes basic communication
Student utilizes appropriate
Student communicates effectively
with patients. Written clinical
strategies. Written clinical encounters
communication strategies with
with most patients. Written clinical
encounters records are
records are occasionally incomplete or
patients. Written clinical
encounters records are prompt,
incomplete, poorly organized,
disorganized. Oral presentations
encounters records cover primary
concise, accurate, thorough,
or illegible. Student fails to
generally organized, but verbose or
problems in a complete and
relevant; important problems
keep appropriate records. Oral
incomplete.
organized manner. Wellreported & adequately explained.
presentations are disorganized
organized, coherent & complete
Oral presentations are complete,
& poorly integrated.
oral presentations.
concise, orderly & polished;
intellectually aggressive; clear
delineation of all clinical issues.
6
7
8
9
10
COMPETENCY 5A: PROFESSIONALISM
Students must demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principals & sensitivity to a diverse
patient population.
Not Observed.
3
4
5
Insensitive to patients and
families. Fails to recognize
appropriate boundaries with
patients. Lacks sensitivity to
patient individuality
Sometimes has difficulty establishing
rapport with patients and families.
Recognizes importance of patient
individuality
Relates well to most patients and
family members. Demonstrates
sensitivity and responsiveness to
patient individuality
3
5
7
4
6
Consistently demonstrates respect,
empathy and compassion for
patients and families. Demonstrates
sensitivity and responsiveness to
patient individuality
8
9
10
Not observed.
5B: WORK HABITS & PERSONAL ACCOUNTABILITY
Poor attendance; shirks
responsibilities;
disorganized. Frequently
late. Fails to assume
appropriate share of team
work. Lacks accountability
Fails to recognize or
address personal limitations
Attends required functions;
assumes expected
responsibilities. Demonstrates
accountability to patients, peers
and team members. Can
recognize personal limitations
Occasionally attends extra functions;
independent initiative; well organized.
Strong sense of accountability to
patients peers and team members.
Recognizes and addresses personal
limitations
Regularly attends extra functions;
assumes leadership roles Strong sense
of accountability to patients, peers and
team members. Recognizes and
addresses personal limitations
3
5
7
9
4
6
8
10
Not observed.
5C: CULTURAL COMPETENCY
Serious gaps in
understanding and
appreciating cultural
differences of patients and
their families.
Learning to understand and
appreciate cultural differences of
patients and their families
Demonstrated understanding and
appreciation of cultural differences of
patients and their families.
Exceptional understanding and
appreciation of cultural differences of
patients and their families.
3
5
7
9
4
6
8
10
Not
observed.
COMPETENCY 6: SYSTEMS-BASED PRACTICE
Students will be able to function effectively in teams and within a larger organizational structure.
Often insensitive to other
health care team members.
Unaware of own
inadequacies. Disrespectful
to other team members
Shows respect for members of the Relates well to health care team
patient care team. Listens and
members. Shows respect for others.
communicates with others.
Interacts constructively with others.
Consistently respects the feelings, needs,
wishes and rights of all health care team
members. Highly regarded as team
member.
3
5
9
4
6
7
8
10
Not included in calculation of clinical grade SUMMARY RECOMMENDATION
I would recommend this
student as a house officer.
3
5
I would enthusiastically recommend
this student as a house officer.
I would actively recruit this student to our
own program.
7
9
Insufficient
Information
I would not recommend this
student as a house officer.
4
6
8
10
FINAL CLINICAL SCORE
** Include instructional prescription for remedy of cp or fail in the summative comments section.
HONORS
Exceptional Performance; Clearly superior.
HIGH PASS
Significantly exceeded the expectations of a third-year student.
PASS
Performed at level expected of a third-year student.
CONDITIONAL PASS **
Warrants significant remedy of attitudes, skills and knowledge.
FAIL **
Unsatisfactory performances.
FORMATIVE COMMENTS (For student’s use in planning future study. NOT for use in Dean's Letter.)
SUMMATIVE COMMENTS (For Dean's Letter of Recommendation)
_________________________________________________________________
SIGNATURE of Preceptor/ Tutor
Date
_________________________________________________________________
Verification SIGNATURE
Date
Nomination to Gold Humanism Honor Society
The Gold Humanism Honor Society recognizes those students who demonstrate exceptional compassion, empathy and concern for others (fellow
students, patients, staff, medical school community and the community at large). It was established to elevate the values of humanism and
professionalism within the field of medicine and its constituent institutions.
Please check here if you wish to recommend this student for election to the Gold Humanism Honor Society. (Comments are not required,
however, if you wish to briefly note the basis for your nomination, please do so.)