ANNUAL ASSESSMENT REVIEW FORM

To be completed by the Educational Supervisorand forwarded with the

TO2 form to the Annual Review of Competence Progression panel

Trainee’s name: ______

StR Year: ______

Name of Assessor: ______

Date of Review: ______

The following review of educational progression must be made after discussion with all consultants involved with the clinical supervision of the trainee, together with the feedback and summary of the TO2 form. The results will be discussed with the trainee before the ARCP panel is convened.

A = Areas of concern

S = Meets standards for year of training

G = Good standard for year of training

  1. GOOD CLINICAL CARE
/ A / S / G / Comments
History & Examination
Patient Management
Clinical/Professional judgment
Reliability/Conscientiousness
Responsibility
  1. DEVELOPING AND MAINTAINING GOOD MEDICAL PRACTICE
/ A / S / G / Comments
Clinical knowledge
Self Motivation
Self Reflection/Insight
IT skills and development
Administrative tasks
Attendance at local educational meetings
  1. WORKING WITH COLLEAGUES
/ A / S / G / Comments
Relationship with staff
Teamworking
Leadership
Referral & delegation
  1. TEACHING AND TRAINING
/ A / S / G / Comments
Clinical teaching
Presentation skills
  1. PROBITY
/ Area of concern / No known areas of concern
  1. HEALTH
/ Area of concern / No known areas of concern
  1. SPECIALTY SKILLS
/ A / S / G / Comments
Operating skills
Labour ward management
  1. CORE OSATS:
Where there are areas of major concern, please supply additional information. In this case it is the responsibility of the College Tutor to alert the TPD/ARCP panel.
When a specific competence has been signed off in the logbook, the trainee should continue to record all procedures undertaken in their log of experience and an occasional OSATS in each skill should still be undertaken, as appropriate.
OSATS / Number undertaken in last year / Number completed at standard required for independent practice in last year / Date competence signed off in logbook (DD/MM/YY)
Fetal blood sampling
Diagnostic hysteroscopy
Diagnostic laparoscopy
Opening and closing the abdomen
Uterine evacuation
Perineal repair
Caesarean section
Operative vaginal delivery
Operative laparoscopy
Manual removal of placenta
Areas of concern etc
  1. MINI CLINICAL EVALUATION EXERCISE (Mini CEX) ANDCASE-BASED DISCUSSIONS (CbDs)

Number of Mini CEX (Gynaecology)
undertaken in last year
Any specific comment:
Number of Mini CEX (Obstetrics)
undertaken in last year
Any specific comment:
Number of Case-based Discussion
(Gynaecology) undertaken in the
last year
Any specific comment:
Number of Case-based Discussion
(Obstetrics) undertaken in the
last year
Any specific comment:
Other Comments
  1. LOGBOOKS– please enter date when module was signed off

No. / Module / Date
Basic / Intermediate / Advanced / Completion of module
1 / Basic Clinical Skills
2 / Teaching Appraisal and Assessment
3 / Information Technology, Clinical Governance and Research
4 / Ethic and Legal Issues
5 / Core Surgical Skills
6 / Postoperative Care
7 / Surgical Procedures
8 / Antenatal Care
9 / Maternal Medicine
10 / Management of Labour
11 / Management of Delivery
12 / Postpartum Problems (The Puerperium)
13 / Gynaecological Problems
14 / Subfertility
15 / Women’s Sexual and Reproductive Health
16 / Early Pregnancy Care
17 / Gynaecological Oncology
18 / Urogynaecology and Pelvic Floor Problems
19 / Professional Development
Comments
  1. ULTRASOUND MODULES - please complete as appropriate

Ultrasound module / Module commenced?
(Y/N ) / Date
commenced / Module progressing appropriately? (Y/N) / Date completed
Basic modules - (for all trainees)
Basic early pregnancy ultrasound (8-12 weeks)
Basic ultrasound assessment of fetal size, liquor and the placenta-
Intermediate modules - (undertaken selectively dependent on ATSM and career intentions)
Intermediate ultrasound of normal fetal anatomy
Intermediate Ultrasound in gynaecology
Intermediate ultrasound of early pregnancy complications
ULTRASOUND OSATS
Where there are areas of major concern, please supply additional information. In this case it is the responsibility of the College Tutor to alert the TPD/ARCP panel.
When a specific competence has been signed off in the logbook, the trainee should continue to record all procedures undertaken in their log of experience and an occasional OSATS in each skill should still be undertaken, as appropriate
Number undertaken
in last year / Number completed at standard required for independent practice in last year / Date competence signed off in logbook (DD/MM/YY)
Basic modules - (for all trainees)
Trans-abdominal ultrasound examination of early (8-12 week) pregnancy:
Fetal measurement, lie and presentation:
Liquor assessment (AFI and maximum pool depth):
Placental assessment:
Intermediate modules - (undertaken selectively dependent on ATSM and career intentions)
Normal Fetal Anatomy and Biometry:
Number undertaken
in last year / Number completed at standard required for independent practice in last year / Date competence signed off in logbook (DD/MM/YY)
Ultrasound assessment of the normal female pelvis:
Ultrasound assessment of uterine fibroids:
Ultrasound assessment of endometrial abnormality:
Ultrasound assessment of pelvic pain:
Ultrasound assessment of ovarian lesions:
Ultrasound diagnosis of normal early pregnancy:
Ultrasound diagnosis of early embryonic demise:
Ultrasound assessment of a woman with suspected ectopic pregnancy:
Areas of concern etc
  1. REFLECTIVE LEARNING –the curriculum highlights where clinical episodes, particularly critical incidents, and educational sessions should be re-visited and re-evaluated as part of a trainee’s routine reflective learning. A diary should be maintained as evidence of reflective learning.

Y/N
Evidence of reflective learning in obstetrics
Evidence of reflective learning in gynaecology
Comments:
  1. PLANNING FOR ATSMs- this process should be formally undertaken at the ST4 ARCP (may be started before this point). This includes confirmingarrangements for completion of any ultrasound modules which must be undertakenprior to commencing certain ATSMs(for example - ‘Normal fetal anatomy and biometry’ ultrasound module must be completed prior to undertaking the ‘Fetal medicine ATSM’)

  1. AUDIT AND TEACHING (undertaken since last Annual Assessment)

  1. ANY OTHER ISSUES OF CONCERN (please outline nature of issues and action plan)

  1. OVERALL ASSESSMENT
Give a brief overview of the Trainee’s main strengths and weaknesses and whether the Trainee is competent to continue into the next year of training
(Note: for LTFT trainees, who are not expecting to progress to the next StR level at this point, please confirm appropriate progress for the present stage of training)
Progress to next year of StR training (tick) / YES / NO
For LTFT trainees, if ‘NO’ – is progress to this point in their training year satisfactory? (tick) / YES / NO
Expected date for progression to next StR level
If there is NO disagreement between the trainee and the assessor about the trainee’s progress, please sign
below
Signature of Educational Supervisor: ______
Print Name:
Date: ____________
Signature of trainee: ______
Date: ______
If there IS disagreement between the assessor and the trainee about the problem areas or lack of progress,
this section should be completed and the documentation from the interview be passed to the TPD or
Chairperson of the Deanery Training Committee/Head of School. Both assessor and trainee should sign to indicate thedisagreement.
I do not agree that I have problems in the area(s)/modules identified.
Areas:
Modules:
Signature of trainee: ______
Date:____________
I have studied the documentation attached and believe that the problems have been accurately identified.
Signature of educational supervisor: ______
Date: ______

Oct2009 version