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Student Name: _________________________Date______________________________Observer Name: ________________________ Clerkship: _________________________ Circle One: AttendingFellow ResidentClerkship week #: ___________________FOCUS: Feedback and Observation of Clinical (UME) StudentsTEAMWORKPlease meet with the student and provide them with feedback based on the teamwork behaviors listed belowAsk student about specific areas they want to work on or areas you should focus your feedback onEncourage student assessment Describe specific behaviors- use CSEF language below as promptsTarget BehaviorsCheck if observed1) Completes requested activities2) Recognizes own role on the team and roles of interprofessional team members3) Integrates into team function, prioritizing team goals4) Demonstrates respectful interactions and is trustworthy5) Communicates effectively with interprofessional team6) Keeps team members informed and up to date7) Actively listens to professional and interprofessional team members’ perspectives and opinionsReach behaviors5) Anticipates and responds to team needs6) Identifies when hospital and community team members (e.g. consults, referrals, PT, social work, VNA) will improve patient care7) Incorporates professional and interprofessional team members’ recommendations into practice? I directly observed this student? I provided verbal feedback to the studentStudent Reflection-What would you change or do differently? Next steps for student growth developed in collaboration with student (please use above behaviors as guide)1.2.3.Supervisor Signature ______________________________ ................
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