Universal Clerkship Evaluation Grading Form



Universal Clerkship Evaluation Grading Form

Xth clerkship -Class of 201X

Student Name: __________

Evaluator: Dr. Gussman Date: _____________

|COMPETENCY1A: PATIENT CARE |

|Students must be prepared to provide patient care that is compassionate, appropriate, and effective |

|HISTORY AND PHYSICAL EXAM |

|Not |Often incomplete or inaccurate |Usually complete and accurate but |Complete & accurate. Histories well |Comprehensive information; thorough & |

|observ|histories. Very poor interviewing|occasionally important information is |organized and comprehensive. Physical exam|precise; questioning identifies subtle |

|ed. |skills. Exam is incomplete; major|missing. May be verbose. Exam is |is complete, properly sequenced, and |problem areas. Excellent interview skills. |

| |deficiencies in technique. |generally complete; occasionally fails|reliable. Good exam skills; identifies |Physical exam thorough, technically sound &|

| |Examination technique is grossly |to follow obvious leads; minor |relevant findings; follows up on important|efficient. Elicits subtle findings; careful|

| |inaccurate. Makes no effort to |deficiencies in technical skill. Makes|areas; technically sound. Sensitive to |attention to clinical findings; anticipates|

| |put patient at ease. |attempt to put patient at ease. |patient needs for comfort and privacy. |patient needs for comfort and privacy. |

| |3 4 |5 |7 |9 |

| | |6 |8 |10 |

|1B.DIAGNOSTIC TESTS & THERAPEUTIC PLANS |

|Not |Frequently overlooks basic tests;|Understands basic tests & their |Has complete & efficient plan for |Efficiently modifies diagnostic strategy as|

|observ|difficulty interpreting results; |interpretation; decisions usually |diagnostic tests & consultation; |results are received; therapeutic program |

|ed. |unable to formulate a treatment |safe; may not be cost-effective. |interprets results correctly; therapeutic |comprehensive, thorough, precise, |

| |plan; decisions risky and/or not | |program complete & safe; uses common |cost-effective. Mature decisions based on |

| |cost-effective. | |sense. |sound integration of data & reasoning. |

| |3 4 |5 |7 |9 |

| | |6 |8 |10 |

|1C.DISEASE PREVENTION/ROUTINE HEALTH MAINTENANCE |

|Not |Rarely raises prevention and |Acknowledges importance of prevention |Often integrates prevention and health |Always integrates prevention and health |

|observ|health maintenance issues. |and health maintenance issues. |maintenance principles and practices into |maintenance principles and practices into |

|ed. | | |health care plan. |health care plan. |

| |3 4 |5 |7 |9 |

| | |6 |8 |10 |

|1D. PROCEDURAL SKILLS |

|Not |Difficulty using proper technique; |Some difficulty using proper technique; |Uses proper techniques; organizes |Timing is precise; procedures performed |

|Observ|awkward with equipment or bypasses |sometimes fails to organize equipment |equipment before procedure; timing is |with ease and dexterity. Able to put |

|ed. |accepted steps; timing, coordination |before procedure; occasional problems with|smooth; coordinated conduct of |patient at ease. |

| |and/or organization are faulty. |timing or coordination. |procedures. | |

| |Technique places self/patient at | | | |

| |risk. | | | |

| |3 4 |5 |7 |9 |

| | |6 |8 |10 |

| |

|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. |

|Not |Poor recall of basic science, |Has basic knowledge of disease processes &|Above average knowledge relevant to assigned|Superior knowledge with mature |

|Observed |pathophysiology & clinical |pathologic events; some ability to relate |patients; able to correlate this knowledge |application to clinical setting; able|

| |information; cannot relate it to|information to clinical material. |consistently with clinical material. |to evaluate/apply recent literature. |

| |cases. | | | |

| |3 4|5 |7 |9 |

| | |6 |8 |10 |

| | | | | |

|2B DIFFERENTIAL DIAGNOSES/ PROBLEM SOLVING |

|Not |Unable to integrate elements of |Somewhat awkward in integrating elements of a|Able to synthesize many aspects of the |Produces sophisticated differential |

|Observed |a clinical knowledge base; has |clinical knowledge base. Can generate short |clinical knowledge base into a |diagnoses and plans; synthesizes |

| |only rudimentary problem-solving|list of appropriate differential diagnoses |differential diagnosis and plan that is |patient's problems according to |

| |ability. Cannot generate problem|for assigned patients. |supported by basic evidence-based |priority.. Diagnostic reasoning and |

| |list or differential diagnosis. | |standards. |testing strategies are astute. |

| |3 4|5 6 |7 |9 |

| | | |8 |10 |

| | | | | |

|COMPETENCY 3: PRACTICE BASED LEARNING AND IMPROVEMENT |

|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. |

| |

|Not |Little evidence of assigned or |Completes reading and study assignments. |Does some supplemental as well as |Self-motivated to expand knowledge; |

|obser|supplemental reading. Cannot accept |Accepts feedback when offered. Takes |assigned reading. Actively solicits and |intellectually curious. Seeks advice |

|ved. |constructive criticism. Fails to share|responsibility for own actions. Will offer|incorporates feedback. Volunteers |and consultation when needed. Is |

| |knowledge with others. |information when solicited. |information with peers. |self-reflective. Takes active role in |

| | | | |sharing information with peers. |

| | | | |Contributes to teaching efforts on the|

| | | | |service |

| |3 4 |5 6|7 |9 |

| | | |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 |

|Not |Student communicates poorly with |Student utilizes basic communication |Student utilizes appropriate |Student communicates effectively with |

|observe|patients. Written clinical |strategies. Written clinical encounters |communication strategies with patients.|most patients. Written clinical |

|d. |encounters records are incomplete, |records are occasionally incomplete or |Written clinical encounters records |encounters records are prompt, concise,|

| |poorly organized, or illegible. |disorganized. Oral presentations generally |cover primary problems in a complete |accurate, thorough, relevant; important|

| |Student fails to keep appropriate |organized, but verbose or incomplete. |and organized manner. Well-organized, |problems reported & adequately |

| |records. Oral presentations are | |coherent & complete oral presentations.|explained. Oral presentations are |

| |disorganized & poorly integrated. | | |complete, concise, orderly & polished; |

| | | | |intellectually aggressive; clear |

| | | | |delineation of all clinical issues. |

| |3 4 |5 6 |7 |9 |

| | | |8 |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 |Insensitive to patients and |Sometimes has difficulty establishing |Relates well to most patients and family |Consistently demonstrates respect, |

|Observe|families. Fails to recognize |rapport with patients and families. |members. Demonstrates sensitivity and |empathy and compassion for patients and|

|d. |appropriate boundaries with |Recognizes importance of patient |responsiveness to patient individuality |families. Demonstrates sensitivity and |

| |patients. Lacks sensitivity to |individuality | |responsiveness to patient individuality|

| |patient individuality | | | |

| |3 4 |5 6|7 |9 |

| | | |8 |10 |

|5B: WORK HABITS & PERSONAL ACCOUNTABILITY |

|Not |Poor attendance; shirks |Attends required functions; assumes |Occasionally attends extra functions; |Regularly attends extra functions; assumes |

|observed|responsibilities; disorganized.|expected responsibilities. |independent initiative; well organized. |leadership roles Strong sense of |

|. |Frequently late. Fails to |Demonstrates accountability to |Strong sense of accountability to |accountability to patients, peers and team |

| |assume appropriate share of |patients, peers and team members. Can|patients peers and team members. |members. Recognizes and addresses personal |

| |team work. Lacks |recognize personal limitations |Recognizes and addresses personal |limitations |

| |accountability Fails to | |limitations | |

| |recognize or address personal | | | |

| |limitations | | | |

| |3 |5 |7 |9 10|

| |4 |6 |8 | |

|5C: CULTURAL COMPETENCY |

|Not |Serious gaps in understanding |Learning to understand and appreciate|Demonstrated understanding and |Exceptional understanding and appreciation of|

|observed|and appreciating cultural |cultural differences of patients and |appreciation of cultural differences of |cultural differences of patients and their |

|. |differences of patients and |their families |patients and their families. |families. |

| |their families. | | | |

| |3 |5 |7 |9 10|

| |4 |6 |8 | |

|COMPETENCY 6: SYSTEMS-BASED PRACTICE |

|Students will be able to function effectively in teams and within a larger organizational structure. |

|Not |Often insensitive to other |Shows respect for members of the |Relates well to health care team |Consistently respects the feelings, needs, |

|observed|health care team members. |patient care team. Listens and |members. Shows respect for others. |wishes and rights of all health care team |

|. |Unaware of own inadequacies. |communicates with others. |Interacts constructively with others. |members. Highly regarded as team member. |

| |Disrespectful to other team | | | |

| |members | | | |

| |3 |5 |7 |9 10|

| |4 |6 |8 | |

Not included in calculation of clinical grade SUMMARY RECOMMENDATION

|Insuffi|I would not recommend this student|I would recommend this student as |I would enthusiastically recommend this |I would actively recruit this student to our |

|cient |as a house officer. |a house officer. |student as a house officer. |own program. |

|Informa| | | | |

|tion | | | | |

| |3 4 |5 |7 |9 10 |

| | |6 |8 | |

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.) [pic][pic][pic]

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