Medical Student Evaluation Form for Obstetrics and Gynecology Clerkship

Student Name:

«Names»

Dates of Rotation:

«Dates»

Evaluator or Team:

«Evaluator»

Service:

«Rotation»

Number of Encounters: (circle one)

Note: Comment section is on the last page.

Core Skills/Behaviors

Fail = 0

Borderline Fail = 1

Pass = 2

HighPass = 3

Honors = 4

N/A

(1) Elicits accurate and appropriate histories



Fail = 0

Borderline Fail = 1

Pass = 2

HighPass = 3

Honors = 4

N/A

Misses essential information

Frequently asks too much or too little history

Gets a complete and accurate history

Skillfully interviews patients

History-taking is consistently precise, perceptive and organized

Insufficient observation/data

(2) Performs complete and appropriate physical examinations



Fail = 0

Borderline Fail = 1

Pass = 2

HighPass = 3

Honors = 4

N/A

Performs inappropriate exams misses major findings

/ Frequently misses findings, and performs inappropriate or faulty exam /

Performs appropriate exams within a reasonable time

Exam thorough, and efficient; uncovers important findings

Exams superb uncovering subtle and important findings

Insufficient observation/data

(3) Defines problems accurately and develops an appropriate differential



Fail = 0

Borderline Fail = 1

Pass = 2

HighPass = 3

Honors = 4

N/A

Fails to identify major problem

Differential diagnosis often incomplete or incorrect

Can develop a well reasoned differential

Differential reflects under- standing of both pathophy- siology and psychosocial issues

Very mature differential

Insufficient observation/data

(4) Orders appropriate diagnostic tests and office procedures



Fail = 0

Borderline Fail = 1

Pass = 2

HighPass = 3

Honors = 4

N/A

Doesn’t understand indications for most procedures and lab tests

Knows indications of some procedures and tests

Understands indications for tests and procedures

Appropriately applies tests and procedures

Exceptionally well-reasoned and individualized use of tests and procedures

Insufficient observation/data

(5)Develops and executes appropriate management plans and follow-up including health promotion and prevention



Fail = 0

Borderline Fail = 1

Pass = 2

HighPass = 3

Honors = 4

N/A

Treatment plans inadequate fails to recognize when urgent treatment is indicated

Plans often neglect important component

Plans are appropriate, complete and timely

Plans always better than average

Superb plans

(6) Uses medical literature and other available resources



Fail = 0

Borderline Fail = 1

Pass = 2

HighPass = 3

Honors = 4

N/A

Fails or refuses to read study or investigate,

Misses important clinical reference information; reads only when asked; uses inappropriate resources

/ Looks up clinical data appropriately; reads up on patients’ problems daily /

Reads more broadly than patients’ problems; actively seeks ancillary clinical data

Reads extensively; communicates findings and actively teaches

Insufficient observation/data

(7) Demonstrates knowledge of pathophysiology of disease and treatment



Fail = 0

Borderline Fail = 1

Pass = 2

HighPass = 3

Honors = 4

N/A

Inadequate knowledge base to care for patient

Knowledge has deficits that require attention

Incorporates knowledge of medicine to appropriately care for patients

Knows more than expected for students at this level of training

Knowledge base is extra- ordinary and dramatically exceeds expectations

Insufficient observation/data

(8) Procedures



Fail = 0

Borderline Fail = 1

Pass = 2

HighPass = 3

Honors = 4

N/A

Unable to perform surgical procedures

Little skill with procedures

Adequate procedural skill

Better procedural skill

Excellent hand eye coordination and tissue handling

Insufficient observation/data

(9) Exhibits behaviors that demonstrate integrity (e.g. reliable, admits error, provides credible explanations)



Fail = 0

Borderline Fail = 1

Pass = 2

HighPass = 3

Honors = 4

N/A

Unreliable and shirks responsibility

Sometimes late, does not always complete responsibilities

Usually punctual, dependable accepts responsibilities

Punctual and seeks new respon-sibilities, always ahead of time

Reliable, dependable and initiates action to improve own performance

Insufficient observation/data

(10) Exhibits behaviors that demonstrate compassion (e.g., feelings for other person’ loss, pain, suffering, stress and death)



Fail = 0

Borderline Fail = 1

Pass = 2

HighPass = 3

Honors = 4

N/A

Unable to comprehend the point of view and emotional state of other people; judgmental of others

Rarely considerate of others feelings and judgmental

/ Appropriately shows concern of others feelings /

Often has genuine concern for patients emotional needs spends some time listening empathetically

Able to create a relaxed environment where others can share feelings, tries to feel and understand the suffering

Insufficient observation/data

(11) Exhibits responsible care of patients



Fail = 0

Borderline Fail = 1

Pass = 2

HighPass = 3

Honors = 4

N/A

Dramatic absence of patient-

doctor communication skills

Establishes rapport with patients, but is often inept or inefficient

Good rapport. Respected by patients and puts them at ease supportive

Quickly and easily earns trust and respect of patients, good listening skills, engenders confidence

Superior rapport, very sensitive to patients unstated needs; is patients advocate

Insufficient observation/data

(12) Establishes good relationships with members of the health care team



Fail = 0

Borderline Fail = 1

Pass = 2

HighPass = 3

Honors = 4

N/A

Disrespectful, rude and insensitive in office or hospital

Often fails to act collegially; communication unclear, incomplete or disorganized

Communicates well, respectful, cooperative and collegial

Strong communication skills and professional demeanor

Mature and collegial; communicates expertly

Insufficient observation/data

COMMENTS, NECESSARY FOR EACH STUDENT’S EVALUATION, TO AMPLIFY THE ABOVE, PARTICULARLY WITH REGARD TO ATTITUDES AND VALUES DESIRABLE FOR A PHYSICIAN, ARE REQUESTED HERE:

SPECIFIC RECOMMENDATIONS FOR IMPROVEMENT:

(NOT FOR DEAN’S LETTER)

Evaluator/Team: ______
Do not send evaluation to Kristine Kline - Completed evaluation goes back to the student.

University of North CarolinaSchool of Medicine / Medical Student Evaluation Form for Obstetrics and Gynecology Clerkship (Rev 8/2005)