Universal Clerkship Evaluation Grading Form

Xthclerkship -Class of 201X

Student Name:______

Evaluator:Dr. GussmanDate:______

COMPETENCY1A: PATIENT CARE
Students must be prepared to provide patient care that is compassionate, appropriate, and effective
HISTORY AND PHYSICAL EXAM
Not observed. / Often incomplete or inaccurate histories. Very poor interviewing skills. Exam is incomplete; major deficiencies in technique. Examination technique is grossly inaccurate. Makes no effort to put patient at ease. / Usually complete and accurate but occasionally important information is missing. May be verbose. Exam is generally complete; occasionally fails to follow obvious leads; minor deficiencies in technical skill. Makes attempt to put patient at ease. / Complete & accurate. Histories well organized and comprehensive. Physical exam is complete, properly sequenced, and reliable. Good exam skills; identifies relevant findings; follows up on important areas; technically sound. Sensitive to patient needs for comfort and privacy. / Comprehensive information; thorough & precise; questioning identifies subtle problem areas. Excellent interview skills. Physical exam thorough, technically sound & efficient. Elicits subtle findings; careful attention to clinical findings; anticipates patient needs for comfort and privacy.
3 4 / 5 6 / 7 8 / 9 10
1B.DIAGNOSTIC TESTS & THERAPEUTIC PLANS
Not observed. / Frequently overlooks basic tests; difficulty interpreting results; unable to formulate a treatment plan; decisions risky and/or not cost-effective. / Understands basic tests & their interpretation; decisions usually safe; may not be cost-effective. / Has complete & efficient plan for diagnostic tests & consultation; interprets results correctly; therapeutic program complete & safe; uses common sense. / Efficiently modifies diagnostic strategy as results are received; therapeutic program comprehensive, thorough, precise, cost-effective. Mature decisions based on sound integration of data & reasoning.
3 4 / 5 6 / 7 8 / 9 10
1C.DISEASE PREVENTION/ROUTINE HEALTH MAINTENANCE
Not observed. / Rarely raises prevention and health maintenance issues. / Acknowledges importance of prevention and health maintenance issues. / Often integrates prevention and health maintenance principles and practices into health care plan. / Always integrates prevention and health maintenance principles and practices into health care plan.
3 4 / 5 6 / 7 8 / 9 10
1D. PROCEDURAL SKILLS
Not Observed. / Difficulty using proper technique; awkward with equipment or bypasses accepted steps; timing, coordination and/or organization are faulty. Technique places self/patient at risk. / Some difficulty using proper technique; sometimes fails to organize equipment before procedure; occasional problems with timing or coordination. / Uses proper techniques; organizes equipment before procedure; timing is smooth; coordinated conduct of procedures. / Timing is precise; procedures performed with ease and dexterity. Able to put patient at ease.
3 4 / 5 6 / 7 8 / 9 10
COMPETENCY 2A: MEDICAL KNOWLEDGE
Students must demonstrate knowledge about established and evolving basic and clinical biomedical sciences, including epidemiology and social/behavioral sciences, and their application of this knowledge to patient care.
Not Observed / Poor recall of basic science, pathophysiology & clinical information; cannot relate it to cases. / Has basic knowledge of disease processes & pathologic events; some ability to relate information to clinical material. / Above average knowledge relevant to assigned patients; able to correlate this knowledge consistently with clinical material. / Superior knowledge with mature application to clinical setting; able to evaluate/apply recent literature.
3 4 / 5 6 / 7 8 / 9 10
2BDIFFERENTIAL DIAGNOSES/ PROBLEM SOLVING
Not Observed / Unable to integrate elements of a clinical knowledge base; has only rudimentary problem-solving ability. Cannot generate problem list or differential diagnosis. / Somewhat awkward in integrating elements of a clinical knowledge base. Can generate short list of appropriate differential diagnoses for assigned patients. / Able to synthesize many aspects of the clinical knowledge base into a differential diagnosis and plan that is supported by basic evidence-based standards. / Produces sophisticated differential diagnoses and plans; synthesizes patient's problems according to priority.. Diagnostic reasoning and testing strategies are astute.
3 4 / 5 6 / 7 8 / 9 10
COMPETENCY 3: PRACTICE BASED LEARNING AND IMPROVEMENT
Students must be able to engage in self-evaluation regarding their academic & clinical performance,
develop plans for personal improvement, and recognize how the application of new learning
can be used to improve patient care.
Not observed. / Little evidence of assigned or supplemental reading. Cannot accept constructive criticism. Fails to share knowledge with others. / Completes reading and study assignments. Accepts feedback when offered. Takes responsibility for own actions. Will offer information when solicited. / Does some supplemental as well as assigned reading. Actively solicits and incorporates feedback. Volunteers information with peers. / Self-motivated to expand knowledge; intellectually curious. Seeks advice and consultation when needed. Is self-reflective. Takes active role in sharing information with peers. Contributes to teaching efforts on the service
3 4 / 5 6 / 7 8 / 9 10
COMPETENCY 4: INTERPERSONAL AND COMMUNICATION SKILLS
Students must be able to demonstrate interpersonal & communication skills, both verbal and written,
that results in effective information exchange with patients, patients’ families, peers, and other health professions colleagues
Not observed. / Student communicates poorly with patients. Written clinical encounters records are incomplete, poorly organized, or illegible. Student fails to keep appropriate records. Oral presentations are disorganized & poorly integrated. / Student utilizes basic communication strategies. Written clinical encounters records are occasionally incomplete or disorganized. Oral presentations generally organized, but verbose or incomplete. / Student utilizes appropriate communication strategies with patients. Written clinical encounters records cover primary problems in a complete and organized manner. Well-organized, coherent & complete oral presentations. / Student communicates effectively with most patients. Written clinical encounters records are prompt, concise, accurate, thorough, relevant; important problems reported & adequately explained. Oral presentations are complete, concise, orderly & polished; intellectually aggressive; clear delineation of all clinical issues.
3 4 / 5 6 / 7 8 / 9 10
COMPETENCY 5A: PROFESSIONALISM
Students must demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principals & sensitivity to a diverse patient population.
Not Observed. / Insensitive to patients and families. Fails to recognize appropriate boundaries with patients. Lacks sensitivity to patient individuality / Sometimes has difficulty establishing rapport with patients and families. Recognizes importance of patient individuality / Relates well to most patients and family members. Demonstrates sensitivity and responsiveness to patient individuality / Consistently demonstrates respect, empathy and compassion for patients and families. Demonstrates sensitivity and responsiveness to patient individuality
3 4 / 5 6 / 7 8 / 9 10
5B: WORK HABITS & PERSONAL ACCOUNTABILITY
Not observed. / Poor attendance; shirks responsibilities; disorganized. Frequently late. Fails to assume appropriate share of team work. Lacks accountability Fails to recognize or address personal limitations / Attends required functions; assumes expected responsibilities. Demonstrates accountability to patients, peers and team members. Can recognize personal limitations / Occasionally attends extra functions; independent initiative; well organized. Strong sense of accountability to patients peers and team members. Recognizes and addresses personal limitations / Regularly attends extra functions; assumes leadership roles Strong sense of accountability to patients, peers and team members. Recognizes and addresses personal limitations
3 4 / 5 6 / 7 8 / 9 10
5C: CULTURAL COMPETENCY
Not observed. / Serious gaps in understanding and appreciating cultural differences of patients and their families. / Learning to understand and appreciate cultural differences of patients and their families / Demonstrated understanding and appreciation of cultural differences of patients and their families. / Exceptional understanding and appreciation of cultural differences of patients and their families.
3 4 / 5 6 / 7 8 / 9 10
COMPETENCY 6: SYSTEMS-BASED PRACTICE
Students will be able to function effectively in teams and within a larger organizational structure.
Not observed. / Often insensitive to other health care team members. Unaware of own inadequacies. Disrespectful to other team members / Shows respect for members of the patient care team. Listens and communicates with others. / Relates well to health care team members. Shows respect for others. Interacts constructively with others. / Consistently respects the feelings, needs, wishes and rights of all health care team members. Highly regarded as team member.
3 4 / 5 6 / 7 8 / 9 10

Not included in calculation of clinical gradeSUMMARY RECOMMENDATION

Insufficient Information / I would not recommend this student as a house officer. / I would recommend this student as a house officer. / I would enthusiastically recommend this student as a house officer. / I would actively recruit this student to our own program.
3 4 / 5 6 / 7 8 / 9 10

FINAL CLINICAL SCORE

** Include instructional prescription for remedy of cp or fail in the summative comments section.

HONORS / Exceptional Performance; Clearly superior.
HIGHPASS / Significantly exceeded the expectations of a third-year student.
PASS / Performed at level expected of a third-year student.
CONDITIONALPASS ** / Warrants significant remedy of attitudes, skills and knowledge.
FAIL ** / Unsatisfactory performances.

FORMATIVE COMMENTS (For student’s use in planning future study. NOT for use in Dean's Letter.)

SUMMATIVE COMMENTS (For Dean's Letter of Recommendation)

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SIGNATURE of Preceptor/ Tutor Date

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Verification SIGNATURE Date

Nomination to Gold Humanism Honor Society

The Gold Humanism Honor Society recognizes those students who demonstrate exceptional compassion, empathy and concern for others (fellow students, patients, staff, medical school community and the community at large). It was established to elevate the values of humanism and professionalism within the field of medicine and its constituent institutions.

Please check here if you wish to recommend this student for election to the Gold Humanism Honor Society. (Comments are not required, however, if you wish to briefly note the basis for your nomination, please do so.)