DA Form 1970 House Staff Evaluation Report

What Is DA Form 1970?

DA Form 1970, House Staff Evaluation Report is a non-mandatory document associated with the evaluation of progression and performance required for each Graduate Medical Education (GME) program participant.

The latest version of the form - sometimes confused with DD Form 1970, Motor Equipment Utilization Record - was released by the Department of the Army (DA) in May 2009 with all previous editions being obsolete. An up-to-date fillable DA Form 1970 is available for download down below or can be found on the Army Publishing Directorate website.

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DATE OF REPORT
HOUSE STAFF EVALUATION REPORT
For use of this form, see AR 351-3; the proponent agency is OTSG.
NAME (Last, First, Middle Initial)
GRADE
SERVICE AS (Check one)
YEAR
INTERN:
ROTATING
STRAIGHT (Specify)
RESIDENT
FELLOW
SPECIALTY
NAME OF HOSPITAL
PERIOD OF SERVICE COVERED BY REPORT
FROM (Day, month, year)
TO (Day, month, year)
SECTION A - GENERAL MEDICAL KNOWLEDGE
1.
2.
Knowledge of disease
3.
Consistently
4.
Has considerable
5.
Is unable to discuss
Has extensive knowledge
disease or pathologic
is fair, but has many
demonstrates
knowledge of disease
of medicine, is aware of
obvious gaps in
adequate knowledge
and pathologic
processes with any
controversial and unsolved
confidence or
fundamental facts.
of disease processes.
processes, and is able to
areas and has intelligently
accuracy.
accurately discuss most
considered various aspects
N?A
N?A
N?A
N?A
N?A
areas of medicine.
of these prob.
SECTION B - OBTAINING MEDICAL HISTORY
6.
7.
8.
9.
10.
Medical histories are
Medical histories
Complete medical
Complete and accurate
Seeks information from all
available sources. Records
totally inadequate for
demonstrate
history obtained and
medical history is neatly
a physician at this
occasional
recorded.
recorded.
pertinent additions to a
level of tng.
inadequacies and/or
complete and accurate
inaccuracies.
history.
N?A
N?A
N?A
N?A
N?A
SECTION C - PERFORMING PHYSICAL EXAMINATION
11.
12.
13.
14.
15.
Physical examinations
Physical examinations
A thorough physical
A complete & unusually
Uses all pertinent ancillary
are totally inadequate
frequently demonstrate
examination is
skillful physical
techniques in addition to
for this level of tng.
inadequacies & or
consistently recorded.
examination is performed
an accurate & skillful
N?A
N?A
N?A
N?A
N?A
inaccuracies.
and recorded.
examination.
SECTION D - DIAGNOSTIC ACUMEN
16.
17.
18.
19.
20.
Consistently derives the
Fails to use available
Occasionally allows
Synthesizes available
Intelligently considers all
data, poor judgement
major gaps or
data into an accurate
available information &
correct diagnosis thru
in the selection of
excesses in diagnostic
differential diagnosis
uses sound judgment in
comprehensive knowledge
diagnostic procedures.
studies thru failure to
& is selective in choice
the selection & sequence
& intelligent interpretation
adequately consider
of further studies.
of studies to arrive at an
of carefully selected
the patient's problem.
accurate diagnosis.
diagnostic procedures.
N?A
N?A
N?A
N?A
N?A
SECTION E - PLANNING, IMPLEMENTING AND EVALUATING THERAPY
21.
22.
23.
24.
25.
Contributes little to
Rarely suggests more
Contributes to
Initiates patient care in
Unusually sound
initial patient evaluation
than routine care, &
planning patient care
an orderly & appropriate
judgement & technical
& rarely suggests a
failure to follow a
& reevaluates patient
manner. Closely
ability is reflected by his
modification of therapy,
patient closely has
frequently to initiate
observes patients course
intelligent & aggressive
poor knowledge &
allowed lapses in
changes or implement
& astutely modifies care
management of all
therapy.
therapy.
as indicated.
patients under his care.
ability in procedural
techniques.
N?A
N?A
N?A
N?A
N?A
SECTION F - KEEPING MEDICAL RECORDS
26.
27.
28.
29.
30.
Infrequent &
Occasional voids in
Maintains neat &
Neat & accurate
Clear & comprehensive
inaccurate notes on
the medical record.
accurate records at
progress notes are
records intelligently
uniformly concise and
patient's progress.
appropriate intervals.
interpret all aspects of
N?A
N?A
N?A
N?A
N?A
informative.
patient care.
SECTION G - FULFILLING ADMINISTRATIVE OBLIGATIONS
31.
32.
33.
34.
Has an excellent grasp
35.
Has little knowledge
Is frequently lax &
Consistently
His comprehensive
or interest in hospital
inaccurate in
demonstrates
of administrative
knowledge & early
and/or army policies &
completing &
willingness & initiative
procedures. Initiates &
completion of hospital &
regulations.
submitting
in complying with
completes forms
army forms expedites
administrative forms
hospital & army
accurately & timely.
patient management &
regulations.
& documents.
affords smooth
administrative functioning
N?A
N?A
N?A
N?A
N?A
of the ward.
SECTION H - INTEREST IN CONTINUED MEDICAL EDUCATION
36.
37.
38.
39.
40.
No evidence of
Little evidence of even
Reads standard
Consistently contributes
An omnivorous reader
outside reading.
text book knowledge
literature pertinent to
current knowledge
actively participates in
his patient's problems.
relative to his patient's
Frequently misses
of his patient's
rounds & conferences,
required rounds &
problems.
Attends required
problems.
supports his statements
conferences.
rounds, conferences &
with accurate reference.
autopsies.
N?A
N?A
N?A
N?A
N?A
SECTION I - ESTABLISHING EFFECTIVE PHYSICIAN-PATIENT RELATIONSHIP
41.
42.
43.
44.
45.
Avoids personal
Is unskillful in eliciting
Is aware of the
Is skillful in eliciting &
Exerts a very positive
contact with patients
or managing the
personal & emotional
dealing with the
influence upon the outlook
& is frequently
personal & emotional
problems of each
emotional & personal
of his patients & enjoys
tactless.
problems of a patient.
patient.
needs of patients & their
the confidence of their
families.
families.
N?A
N?A
N?A
N?A
N?A
PREVIOUS EDITIONS ARE OBSOLETE.
PAGE 1 OF 2
DA FORM 1970, MAY 2009
APD LC v1.00ES
DATE OF REPORT
HOUSE STAFF EVALUATION REPORT
For use of this form, see AR 351-3; the proponent agency is OTSG.
NAME (Last, First, Middle Initial)
GRADE
SERVICE AS (Check one)
YEAR
INTERN:
ROTATING
STRAIGHT (Specify)
RESIDENT
FELLOW
SPECIALTY
NAME OF HOSPITAL
PERIOD OF SERVICE COVERED BY REPORT
FROM (Day, month, year)
TO (Day, month, year)
SECTION A - GENERAL MEDICAL KNOWLEDGE
1.
2.
Knowledge of disease
3.
Consistently
4.
Has considerable
5.
Is unable to discuss
Has extensive knowledge
disease or pathologic
is fair, but has many
demonstrates
knowledge of disease
of medicine, is aware of
obvious gaps in
adequate knowledge
and pathologic
processes with any
controversial and unsolved
confidence or
fundamental facts.
of disease processes.
processes, and is able to
areas and has intelligently
accuracy.
accurately discuss most
considered various aspects
N?A
N?A
N?A
N?A
N?A
areas of medicine.
of these prob.
SECTION B - OBTAINING MEDICAL HISTORY
6.
7.
8.
9.
10.
Medical histories are
Medical histories
Complete medical
Complete and accurate
Seeks information from all
available sources. Records
totally inadequate for
demonstrate
history obtained and
medical history is neatly
a physician at this
occasional
recorded.
recorded.
pertinent additions to a
level of tng.
inadequacies and/or
complete and accurate
inaccuracies.
history.
N?A
N?A
N?A
N?A
N?A
SECTION C - PERFORMING PHYSICAL EXAMINATION
11.
12.
13.
14.
15.
Physical examinations
Physical examinations
A thorough physical
A complete & unusually
Uses all pertinent ancillary
are totally inadequate
frequently demonstrate
examination is
skillful physical
techniques in addition to
for this level of tng.
inadequacies & or
consistently recorded.
examination is performed
an accurate & skillful
N?A
N?A
N?A
N?A
N?A
inaccuracies.
and recorded.
examination.
SECTION D - DIAGNOSTIC ACUMEN
16.
17.
18.
19.
20.
Consistently derives the
Fails to use available
Occasionally allows
Synthesizes available
Intelligently considers all
data, poor judgement
major gaps or
data into an accurate
available information &
correct diagnosis thru
in the selection of
excesses in diagnostic
differential diagnosis
uses sound judgment in
comprehensive knowledge
diagnostic procedures.
studies thru failure to
& is selective in choice
the selection & sequence
& intelligent interpretation
adequately consider
of further studies.
of studies to arrive at an
of carefully selected
the patient's problem.
accurate diagnosis.
diagnostic procedures.
N?A
N?A
N?A
N?A
N?A
SECTION E - PLANNING, IMPLEMENTING AND EVALUATING THERAPY
21.
22.
23.
24.
25.
Contributes little to
Rarely suggests more
Contributes to
Initiates patient care in
Unusually sound
initial patient evaluation
than routine care, &
planning patient care
an orderly & appropriate
judgement & technical
& rarely suggests a
failure to follow a
& reevaluates patient
manner. Closely
ability is reflected by his
modification of therapy,
patient closely has
frequently to initiate
observes patients course
intelligent & aggressive
poor knowledge &
allowed lapses in
changes or implement
& astutely modifies care
management of all
therapy.
therapy.
as indicated.
patients under his care.
ability in procedural
techniques.
N?A
N?A
N?A
N?A
N?A
SECTION F - KEEPING MEDICAL RECORDS
26.
27.
28.
29.
30.
Infrequent &
Occasional voids in
Maintains neat &
Neat & accurate
Clear & comprehensive
inaccurate notes on
the medical record.
accurate records at
progress notes are
records intelligently
uniformly concise and
patient's progress.
appropriate intervals.
interpret all aspects of
N?A
N?A
N?A
N?A
N?A
informative.
patient care.
SECTION G - FULFILLING ADMINISTRATIVE OBLIGATIONS
31.
32.
33.
34.
Has an excellent grasp
35.
Has little knowledge
Is frequently lax &
Consistently
His comprehensive
or interest in hospital
inaccurate in
demonstrates
of administrative
knowledge & early
and/or army policies &
completing &
willingness & initiative
procedures. Initiates &
completion of hospital &
regulations.
submitting
in complying with
completes forms
army forms expedites
administrative forms
hospital & army
accurately & timely.
patient management &
regulations.
& documents.
affords smooth
administrative functioning
N?A
N?A
N?A
N?A
N?A
of the ward.
SECTION H - INTEREST IN CONTINUED MEDICAL EDUCATION
36.
37.
38.
39.
40.
No evidence of
Little evidence of even
Reads standard
Consistently contributes
An omnivorous reader
outside reading.
text book knowledge
literature pertinent to
current knowledge
actively participates in
his patient's problems.
relative to his patient's
Frequently misses
of his patient's
rounds & conferences,
required rounds &
problems.
Attends required
problems.
supports his statements
conferences.
rounds, conferences &
with accurate reference.
autopsies.
N?A
N?A
N?A
N?A
N?A
SECTION I - ESTABLISHING EFFECTIVE PHYSICIAN-PATIENT RELATIONSHIP
41.
42.
43.
44.
45.
Avoids personal
Is unskillful in eliciting
Is aware of the
Is skillful in eliciting &
Exerts a very positive
contact with patients
or managing the
personal & emotional
dealing with the
influence upon the outlook
& is frequently
personal & emotional
problems of each
emotional & personal
of his patients & enjoys
tactless.
problems of a patient.
patient.
needs of patients & their
the confidence of their
families.
families.
N?A
N?A
N?A
N?A
N?A
PREVIOUS EDITIONS ARE OBSOLETE.
PAGE 1 OF 2
DA FORM 1970, MAY 2009
APD LC v1.00ES
SECTION J - ATTITUDE AND APPEARANCE
46.
47.
48.
49.
50.
Slovenly immature &
Occasionally boisterous
Is aware of
Is unusually mature in
His maturity, behavior
often inappropriate
or sullen, has little
professional position
his judgement &
integrity & grooming are
in behavior.
insight of problems of
& responsibilities,
interpersonal
consistent with the highest
co-workers.
behavior &
relationships, is always
ideals of the profession.
appearance are
courteous & well
consistently
groomed.
N?A
N?A
N?A
N?A
N?A
appropriate.
SECTION K - WORKING WITH OTHERS
51.
52.
53.
54.
55.
A thoughtful,
Unusually cognizant of
His perception &
A malcontent who is
Has little understanding
the source of many
of co-workers
considerate person
personnel & personality
understanding of
complaints by
problems. Makes
who respects the
problems, his insight is
interpersonal relationships
hospital personnel.
excessive demands &
rights & problems of
helpful in establishing &
allows anticipation &
is not thoughtful of
all co-workers.
maintaining a
correction of potential
ways to make work
harmonious milieu.
problem areas, thereby
groups function
establishing an excellent
without friction.
working situation.
N?A
N?A
N?A
N?A
N?A
SECTION L - LEADERSHIP AND RESPONSIBILITY
56.
57.
58.
59.
60.
Totally passive,
Assumes responsibility
Readily assumes
Consistently
Aggressively assumes
refuses to accept
only when stimulated
responsibility &
demonstrates skill,
medical responsibilities,
responsibility or
to do so.
initiative, is
initiative & capability as
devotes time & energy
initiative.
respected by patients
a physician. Enjoys
selflessly to all duties. Is
and co-workers.
responsibility in all
respected by his peers.
spheres.
N?A
N?A
N?A
N?A
N?A
SECTION M - SELF-EVALUATION AND THE USE OF CONSULTANTS
61.
62.
63.
64.
65.
Has no concept of his
Limitations in both
Recognizes his
Excellent insight into his
Consistently demonstrates
inadequacies, & has
knowledge &
limitations & assumes
own limitations & uses
excellent judgment in his
ignored counselling.
experience have
responsibilities
the proper consultant to
initiative, inquisitiveness,
frequently led to
proportionate to his
aid in patient
assumption of
misuse (too little or too
knowledge. Uses
management as well as
responsibility & the use of
great) of consultants.
consultations in an
to benefit personally.
consultants.
appropriate manner.
N?A
N?A
N?A
N?A
N?A
PART IV - OVERALL EVALUATION (Counselling With House Officer by Rater is Required)
66.
UNSATIS -
66.
MARGINAL
68.
BELOW
69.
EFFECTIVE &
70.
VERY
71.
EXCEPTION-
72.
OUT-
FACTORY
AVERAGE
COMPETENT
FINE
ALLY FINE
STANDING
x
xxxx
xxxxxx
xxxxxxxx
xx
xx
xxxxxxxxxx
xxxx
x x
xxxxxx
x x
xxxxxxxxxxxx
xxxxx
x
x x x
xxxxxxxx
xxxxxxxxxxxxxx
xxxxxx
x x x
x
Performance
Lacks motivation,
May continue in
Satisfactorily meets the
A continuing
Performs
Extremely rare.
fails to meet
interest & capability.
program, but
stated objectives.
level of high
outstandingly in
Excellence in
standards of
Performance is
performance is
performance in
most aspects of his
everything.
acceptance.
limited. Cannot
below
most aspects of
job. Initiative,
Performs far
Rehabilitation is
continue without
standards.
stated
leadership &
beyond his level of
doubtful.
substantial
objectives.
personality are
training.
improvement.
worthy of special
notice.
PART V - RECOMMENDATION FOR ADDITIONAL TRAINING
73. HIGHLY RECOMMEND
74. WOULD ACCEPT FOR
75. MIGHT BE EXPECTED TO
76. SHOULD NOT BE
AND WOULD ACCEPT FOR
ADDITIONAL TRAINING IN:
DO WELL IN A TRAINING
CONSIDERED FOR
ADDITIONAL TRAINING IN:
PROGRAM IN:
ADDITIONAL TRAINING IN:
PART VI - NARRATIVE DESCRIPTION OF PERFORMANCE AND PERSONAL QUALITIES
NAME OF SERVICE CHIEF
SIGNATURE
DATE
NAME OF DIRECTOR OF MEDICAL EDUCATION
SIGNATURE
DATE
APPROVED (Name of Hospital/Facility Commander)
SIGNATURE
DATE
PAGE 2 OF 2
DA FORM 1970, MAY 2009
APD LC v1.00ES

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DA Form 1970 Instructions

Filing procedures for the DA Form 1970 are as follows:

  1. The form requires the name, grade, intern status (rotating or straight) and specialty of the participant along with the name of the hospital and the period of service covered by the report.
  2. Part I of the DA 1970 covers clinical performance and contains Sections A through F. Each section contains a scale from 1 to 4. T he participant's performance is numerically rated on each criteria within the provided range.
    • Section A assesses the level of general medical knowledge.
    • Section B is for evaluating the handling of medical history records.
    • Section C specifies the way the physical examinations are performed.
    • Section D evaluates diagnostic acumen.
    • Section E describes how well therapy is planned, implemented and evaluated.
    • Section F refers to the way medical records are kept.
  3. Part II - Assuming Responsibilities - contains three more sections.
    • Section G assesses how well administrative obligations are fulfilled.
    • Section H shows the level of interest in pursuing further medical education.
    • Section I of the DA Form 1970 evaluates the participant's ability to establish an effective physician-patient relationship.
  4. Part III - Personal Qualities Assessment - covers Sections J through M.
    • Section J evaluates the attitude and appearance.
    • Section K assesses the effectiveness of cooperation.
    • Section L is for evaluating the levels of leadership and responsibility skills.
    • Section M is for assessing the accuracy of self-evaluation and the role of the consultant.
  5. Part IV of the form calls for an overall evaluation. This part requires counseling with the House Officers done by the Rater.
  6. Part V contains recommendations for additional training in case any is needed.
  7. Part VI contains an additional block for a narrative description of the participant's performance and personal qualities.

The DA 1970 needs to be verified by the signatures of the Service Chief, the Director of Medical Education and a hospital or facility commander.



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