MARSHALL UNIVERSITY MEDICAL CENTER



MARSHALL UNIVERSITY MEDICAL CENTER

FACULTY EVALUATION OF STUDENT PERFORMANCE

| |MUSOM Course # : |Preceptor/Attending Name: |PLEASE RETURN COMPLETED FORM TO: |

| | | |_______________________________________________ |

| | | |FOR A VISITING ELECTIVE, RETURN COMPLETED FORM TO: |

| | | |MUJCESOM, Office of Academic Affairs |

|Student Name | | |1600 Medical Center Dr., Huntington, WV 25701 |

| | | |BY FAX: 304-691-1740; BY EMAIL: morton9@marshall.edu |

| |Course Description: | | |

| |DATES: |LOCATION: | |

| |NUMBER OF DAYS MISSED: | | |

| |REASON (S): | | |

DOES THIS STUDENT PASS PROFESSIONALISM? YES NO IF NO, STOP HERE, AND DO NOT COMPLETE EVALUATION!

Please comment on the student's performance noting strengths and Weaknesses:_____________________________________________

_____________________________________________________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________________________________________

Are there any aspects of this student's performance that suggest a need for special attention? YES NO MAYBE

Degree of confidence in your estimate of the student: Very confident Fairly confident Not at all confident

| |1 |2 |3 |4 |5 |

|PROFESSIONALISM |Does not accept responsibility; |Generally denies responsibility; |Usually exhibits good judgment in |Often exhibits good judgment and |Exceptional professional |

| |inappropriate or immature |frequently uses inappropriate or |personal and professional |maturity. |conduct; demonstrates |

| |behavior |immature behavior; |situations | |maturity, excellent judgment |

| |1 |2 |3 |4 |5 |

|SELF DIRECTED |Does not exhibit motivation, |Frequently does not explore |Conscientious worker who is |Often shows interest in |Exceptionally hard worker who |

|LEARNING/ |shows little evidence of |independent learning |receptive to teaching and |independent learning |maximizes learning |

| |independent work |opportunities |feedback |opportunities and feedback |opportunities |

|LEARNING ATTITUDE | | | | | |

| |1 |2 |3 |4 |5 |

|INTERACTIONS WITH |Relationships are often distant, |Relationships are cool or awkward |Usually forms constructive, |Conveys exceptional warmth and |Skillfully uses rapport for |

|PATIENTS |strained or dysfunctional | |professional relationships |understanding |therapeutic gain |

| |1 |2 |3 |4 |5 |

|BASIC CLINICAL |Major deficiencies in many areas |Generally adequate with minor |Generally appropriate to student level |Generally above average depth in |Outstanding |

|KNOWLEDGE | |deficiencies in important areas | |important areas | |

| |1 |2 |3 |4 |5 |

|CLINICAL REASONING |Usually illogical or impractical |Frequently illogical or impractical |Usually logical and practical |Almost always logical & practical |Frequent astute insights |

|SKILLS | | | | | |

| |1 |2 |3 |4 |5 |

|HISTORY TAKING SKILLS |Often misses major important findings|Frequently misses relevant data or |Usually elicits most relevant data; |Almost always elicits all relevant |Elicits data efficiently and in |

| | |obtains inaccurate information |almost always accurate |clinical data; always accurate |great depth, when appropriate |

| |1 |2 |3 |4 |5 |

|PHYSICAL EXAMINATION |Often misses major important findings|Frequently misses or makes inaccurate |Usually identifies findings accurately |Almost always identifies important |Often discovers subtle physical |

|SKILLS | |findings | |findings with accuracy |findings |

| |1 |2 |3 |4 |5 |

|DIAGNOSTIC |Often does not identify major patient|Frequently identifies major patient |Usually identifies major patient |Often reveals exceptional insight; |Often reveals exceptional insight; |

|DECISION-MAKING SKILLS |problems; Differential diagnosis |problems; Differential diagnosis skills |problems; Differential diagnosis skills|Differential diagnosis skills are above|Differential diagnosis skills are |

| |skills are poor |are adequate |are appropriate to level |average |excellent |

FINAL EXAM SCORE: _________

FINAL GRADE: (Please circle): A B C or P F ________________________ ______________

I attest that I have had no provider relationship with this student. Faculty Signature Date

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