GERIATRIC PSYCHIATRY FELLOW COMPETENCY ASSESSMENT FORM
Fellow: ___________________________ Attending_______________________________
Site of Rotation _____________________ Date of Rotation _______________________
ACGME
Comp.**
Please circle the number that best describes the resident's ability in each of the following items:
Interviewing skills: Misses important
information, poor rapport, misses emotional
cues. Unaware of cultural and diversity issues.
Judgmental. Unable to communicate diagnosis
or treatment plan.
Case Presentations: Incomplete,
disorganized, superficial. Mental status does
not identify pertinent info.
Fund of Knowledge: Poor knowledge of
diagnostic criteria, pathophysiology and
therapy, including mechanisms of meds.
Clinical Judgment: Difficulty identifying
pertinent clinical data or integrating clinical
data with medical knowledge. Indecisive.
Fails to prioritize patient problems.
Formulation of Problem/Treatment Plan:
Incomplete, not aware of social or medical
issues that might complicate treatment and
compliance. Does not utilize other resources
in disposition planning.
1 2
3 4
1 2
3 4
1 2
3 4
1 2
3 4
1 2
3 4
Documentation: Incomplete, illegible, not
properly titled, dated, timed, or signed. Not
informative. Progress notes/discharge
summaries not completed in a timely manner
Effort To Learn/Initiative: No evidence of
or motivation for independent learning.
1 2
3 4
1 2
3 4
Professionalism: Dishonest, defensive,
disrespectful. Late, ineffective time management, misses meetings, not accountable. Does
not answer pages. Inappropriate behavior or
dress.
Supervision: Defensive, does not bring issues
to supervisor. Late, unprepared.
Interaction With System of Care:
Difficulties with families, other disciplines.
Easily frustrated with barriers to ensuring
comprehensive care. Does not arrange or take
part in family meetings.
Boundary issues: Intrusive, inappropriately
personal or impersonal. Does not maintain
appropriate doctor patient relationship.
Leadership: Passive in situations requiring
physician leadership. Defers to others to set
agendas and solve problems. Ineffective in
communicating with others. Mis-uses authority
over others.
Teaching: Makes no effort to include
students. Does not teach effectively.
1 2
3 4
1 2
3 4
1 2
3 4
1 2
5 Complete, empathetic, nonjudgmental, attuned to
dynamic issues and nuances of behavior, thought
process and content. Listens carefully, respectful of
cultural/diversity issues. Communicates treatment
plan effectively.
5 Concise, organized; thorough; pertinent positives and
negatives elucidated. Uses recognized logical
approach.
5 Extensive knowledge: knows pathophysiology and
mechanisms of meds. Able to develop complete diff.
dx.
5 Consistently identifies pertinent clinical data and
integrates data with medical knowledge. Reasons
effectively in ambiguous clinical situations.
Effectively prioritizes patient problems.
5 Complete list of patient’s problems including
psychiatric, psychological, medication, social and
medical issues. Integrates into formulation/treatment
plan. Thinks through risks and benefits of
interventions. Involves other resources in disposition
planning.
5 Complete, well organized, legible, concise, timely
and reflective of patient’s status.
N/A
A,B,D,
E
A,B,D,
E
A,B,
A,B,C,
F
A,B,
A,B,C,
D,E,F,
5 Self-directed, consistently demonstrates use of
resources including texts, journals and MedLine.
Initiates academic projects.
5 Respectful, effective time management, reliable.
Committed to patient care. Maintains high ethical
standards for self and others. Establishes trust with
others.
A,B,C,
E,F,
5 Not defensive, asks for feedback, makes constructive
changes in response to supervision.
5 Respectful and compassionate with families and
other disciplines. Ensures comprehensive care.
Actively involved in family meetings.
A,C,D,
E
A,D,E,
F
3 4
5 Able to maintain professional relationships and
provides patient centered care.
A,B,D,
E
1 2
3 4
5 Active in recognizing and takes initiative in solving
problems. Communicates effectively with others.
Mobilizes appropriate resources. Uses authority
constructively.
A, B,
D, E
1 2
3 4
5 Includes students, teaches effectively, mentors, acts
as a role model. Brings in and cites literature.
B,C,D,
E,F
A,D,E,
F
**ACGME Competencies – Each assessed item relates to one or more of the following competencies:
A. Patient Care
B. Knowledge
C. Practice-Based Learning
D. Interpersonal Communication
E. Professionalism
F. Systems-Based Practice
GERIATRIC PSYCHIATRY FELLOW COMPETENCY ASSESSMENT FORM
COMMENTS:
Please describe strengths and specific areas for growth and improvement:
Assessment Sources
Number of Cases Assessed _______
Direct Observation of resident/patient interactions ______
Chart Stimulated Recall
_____
Frequency of Supervisor Contacts _____________
Oral Presentation _____
Other (specify) ____________________________________
Direct feedback regarding this evaluation has been given to the resident: YES ____ NO ____
Attending Signature: ___________________________
Date: __________________
Resident Signature: ____________________________
Date: __________________
For Psychotherapy Supervisors Only:
Type of Supervision: { } Brief
{ } Other
{ } Psychodynamic
{ } Supportive
{ } CBT
{ } Family/Couples
{ } Group
Choice of therapeutic modality: Unable to assess
diagnostic and other issues that inform decision for type
of therapy. Superficial understanding of modalities.
1
2
3
4
5
Therapist-Patient Relationship: Unable to
communicate effectively or to develop rapport with the
patient. Unable to identify pertinent themes.
Ineffectively deals with patient's feelings about the
therapist.
Uses techniques of specific therapy: Inadequate
knowledge of techniques, does not apply principles.
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2
3
4
5
Were patients supervised
on medications?
Yes / No
Choice of therapeutic modality: Good
understanding of different modalities (supportive,
insight oriented, CBT etc.) and patient
characteristics that would inform choice.
Effectively communicates and develops rapport
with patient. Perceptive about major themes. Deals
effectively with patient's feelings toward the
therapist.
Sophisticated in the use of specific techniques of
the therapy, and applies knowledge and uses
supervision to improve.
* Based on forms created by Judith Neugroschl, MD, Mount Sinai School of Medicine and
Robert Rohrbaugh, MD, Yale University School of Medicine. Used with permission.
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