Family Medicine Clerkship Student Evaluation Form

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FAMILY MEDICINE CLERKSHIP STUDENT EVALUATION
Student _______________________________________ Site_______________________________
Evaluator _____________________________________ Dates _____________________________
Use the following scale to rate the student on the 16 listed areas AND the student’s overall performance
Unacceptable
Marginal Performance
Typical Performance
Superior Performance
Honors
(Needs improvement)
(Expected for UVA Student)
(Top 20%)
(Top5%)
1
2
3
4
5
Designations of “Unacceptable”, “Marginal” and “Honors” require supporting evidence in the required narrative comments
Evaluation:
(Circle appropriate rating)
(NA/CA=not applicable; cannot assess)
1. Clinical knowledge base
1
2
3
4
5
NA/CA
Depth and integration of pertinent clinical and basic science knowledge
2. Ability to engage and
1
2
3
4
5
NA/CA
communicate with patients
Ability to initiate communications, listen effectively, and convey information to patients and families
3. Ability to perform a focused
1
2
3
4
5
NA/CA
and time-efficient history
Completeness of history (appropriate for the clinical situation); use of logical approach; asks follow-up questions
4.
Ability to perform a pertinent
1
2
3
4
5
NA/CA
physical examination
Completeness, accuracy, ability to direct exam to patient’s problems. Ability to elicit/interpret findings
5.
Ability to select, justify and
1
2
3
4
5
NA/CA
interpret basic diagnostic studies
Selects appropriate diagnostic studies, including lab tests. Interprets results
6. Ability to present
1
2
3
4
5
NA/CA
information orally
Presents in a complete, accurate, and organized fashion. Gives appropriate detail for the clinical setting
7. Ability to keep appropriate
1
2
3
4
5
NA/CA
written clinical records
Completeness, accuracy, organization. Appropriate detail given.
8. Ability to generate and
1
2
3
4
5
NA/CA
refine an appropriate
diagnosis/differential diagnosis
Uses patient information to generate appropriate diagnosis/differential diagnosis.
9.
Ability to develop an immediate
1
2
3
4
5
NA/CA
and appropriate plan of care
Uses clinical and laboratory information to develop a diagnostic, clinical care, and treatment plan
10. Ability to prognose illness
1
2
3
4
5
NA/CA
and plan for follow-up
Understands implications of patient’s illness, including prognosis, and can plan for follow-up
11. Technical/procedural skills
1
2
3
4
5
NA/CA
Demonstrates technical/procedural skills appropriate for this clerkship and the student’s stage of training.
12. Ability to access & apply
1
2
3
4
5
NA/CA
literature resources
Identifies, accesses, and utilizes current medical information in the care of patients. Shares information with colleagues.
Student Evaluation Form, page 2
FAMILY MEDICINE CLERKSHIP STUDENT EVALUATION
Student _______________________________________ Site_______________________________
Evaluator _____________________________________ Dates _____________________________
Use the following scale to rate the student on the 16 listed areas AND the student’s overall performance
Unacceptable
Marginal Performance
Typical Performance
Superior Performance
Honors
(Needs improvement)
(Expected for UVA Student)
(Top 20%)
(Top5%)
1
2
3
4
5
Designations of “Unacceptable”, “Marginal” and “Honors” require supporting evidence in the required narrative comments
Evaluation:
(Circle appropriate rating)
(NA/CA=not applicable; cannot assess)
1. Clinical knowledge base
1
2
3
4
5
NA/CA
Depth and integration of pertinent clinical and basic science knowledge
2. Ability to engage and
1
2
3
4
5
NA/CA
communicate with patients
Ability to initiate communications, listen effectively, and convey information to patients and families
3. Ability to perform a focused
1
2
3
4
5
NA/CA
and time-efficient history
Completeness of history (appropriate for the clinical situation); use of logical approach; asks follow-up questions
4.
Ability to perform a pertinent
1
2
3
4
5
NA/CA
physical examination
Completeness, accuracy, ability to direct exam to patient’s problems. Ability to elicit/interpret findings
5.
Ability to select, justify and
1
2
3
4
5
NA/CA
interpret basic diagnostic studies
Selects appropriate diagnostic studies, including lab tests. Interprets results
6. Ability to present
1
2
3
4
5
NA/CA
information orally
Presents in a complete, accurate, and organized fashion. Gives appropriate detail for the clinical setting
7. Ability to keep appropriate
1
2
3
4
5
NA/CA
written clinical records
Completeness, accuracy, organization. Appropriate detail given.
8. Ability to generate and
1
2
3
4
5
NA/CA
refine an appropriate
diagnosis/differential diagnosis
Uses patient information to generate appropriate diagnosis/differential diagnosis.
9.
Ability to develop an immediate
1
2
3
4
5
NA/CA
and appropriate plan of care
Uses clinical and laboratory information to develop a diagnostic, clinical care, and treatment plan
10. Ability to prognose illness
1
2
3
4
5
NA/CA
and plan for follow-up
Understands implications of patient’s illness, including prognosis, and can plan for follow-up
11. Technical/procedural skills
1
2
3
4
5
NA/CA
Demonstrates technical/procedural skills appropriate for this clerkship and the student’s stage of training.
12. Ability to access & apply
1
2
3
4
5
NA/CA
literature resources
Identifies, accesses, and utilizes current medical information in the care of patients. Shares information with colleagues.
Student Evaluation Form, page 2
13. Clinical judgment
1
2
3
4
5
NA/CA
Can integrate medical knowledge with clinical information in the care of patients. Weighs risks/benefits.
14. Humanistic attributes
1
2
3
4
5
NA/CA
Demonstrates empathy, altruism, sensitivity, respect for the individual, professionalism.
15. Relationships with staff
1
2
3
4
5
NA/CA
and colleagues
Ability to interact cooperatively with other members of team. Respectful, professional
16. Attitude, interest, and
1
2
3
4
5
NA/CA
responsibility
Reliable, available, prompt. Participates actively in rounds and teaching conferences. Assumes responsibility and is
dependable.
Use the following scale to rate the student’s overall performance
Unacceptable
Marginal Performance
Typical Performance
Superior Performance
Honors
(Needs improvement)
(Expected for
(Top 20%)
(Top5%)
a UVA student)
1
2
3
4
5
Designations of “Unacceptable” , “Marginal” and “Honors” require supporting evidence in the required narrative comments.
OVERALL PERFORMANCE:
1
2
3
4
5
Cannot rate(explain below)
Contact with student: _________Minimal (1-2 clinics/sessions) __________Moderate (3-5 days) ___________ Extensive (1-2 weeks)
NARRATIVE COMMENTS (required):
Narrative comments are essential in the evaluation process and offer important points of feedback in contributing to the
professional development of the student physician. Evaluations must provide a clear and forthright picture of the student. Be
honest and fair, as these comments may be used in their entirety in the student’s Medical School Performance Evaluation
(formerly known as the Dean’s Letter). Use an additional sheet if necessary.
Have you discussed this evaluation with the student?
Yes____No______
Have you observed this student interacting with patients/families? Yes___ No_____
Have you observed this student perform: elements of the history/physical exam? Yes____ No_____
PLEASE HAVE STUDENT RETURN THIS FORM OR FAX WITHIN ONE WEEK TO: 434-982-0390

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