Unacceptable 1 Below expectations




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I. Clinical Knowledge and Skills



Unacceptable

1


Below expectations

2


Meets Expectations

3


Exceeds Expectations

4


Exceptional

5


Knowledge in Subject Area:

Includes level of knowledge and application to clinical problems.






  • Rarely demonstrates understanding of basic principles.

  • Rarely applies knowledge to specific patient conditions.



  • Often demonstrates understanding of basic principles.

  • Often applies knowledge to specific patient conditions.


  • Consistently demonstrates understanding of basic and some complex principles.

  • Consistently applies knowledge to specific patient conditions.

  • Almost always demonstrates understanding of basic and most complex principles.

  • Almost always applies knowledge to specific patient conditions



Data Gathering Skills:


Includes basic history and physical examination.

  • Does not obtain basic history and physical

  • Rarely obtains basic history and physical.

  • Often obtains basic history and physical.

  • Consistently obtains basic history and physical.

  • Almost always obtains basic history and physical.

Clinical Reporting Skills:

Includes oral case presentations, written or dictated notes, histories, and physical exams.


  • Does not communicate medical histories and physical exams in an organized or complete manner.

  • Rarely communicates medical histories and physical exams in an organized or complete manner

  • Often communicates medical histories and physical exams in an organized or complete manner.

  • Consistently communicates medical histories and physical exams in an organized or complete manner.

  • Almost always communicates medical histories and physical exams in an organized or complete manner.

Procedural Skills:

Includes knowledge, performance and attention to patient comfort and dignity.



  • Not attentive to patient comfort or dignity.

  • Demonstrates poor motor skills that result in inadequate performance of tasks.

  • Rarely attentive to patient comfort or dignity.

  • Rarely demonstrates good motor skills that result in an adequate performance of a task.




  • Consistently attentive to patient comfort and dignity.

  • Consistently demonstrates good motor skills that result in an adequate performance of task.




  • Almost always attentive to patient comfort and dignity.

  • Almost always demonstrates excellent motor skills that result in an adequate performance of task.



FAMILY MEDICINE CLERKSHIP FEEDBACK AND EVALUATION FORM Name:__________________________

Location: _______________________

The Family Medicine Clerkship is a mastery-based required clerkship. Evaluation is primarily based on the students performance in the last 2-3 weeks of the clerkship with possible exceptions involving unacceptable professional behavior. Review the anchors in each category and select the category that most closely mirrors the student's performance in that area. The anchors are not a checklist where all items are required to achieve a particular grade.


CLINICAL SKILLS SECTION
COMMENTS:


  1. CLINICAL KNOWLEDGE AND SKILLS (Constructive criticism will not appear in the dean’s letter unless there is a pattern of similar behavior across other clerkships)










CLINICAL SKILLS SECTION

II. Patient Care Skills



Unacceptable

1


Below Expectations

2


Meets Expectations

3


Exceeds Expectations

4


Exceptional

5


Integration Skills: Includes problem-solving skills, ability to use data from patient interview, physical examination, and ancillary tests to identify major and minor patient problems in an organized and efficient manner.
  • Does not independently identify major patient problems.
  • Unable to problem solve and organize issues efficiently.




  • Rarely able to independently identify and prioritize major problems.

  • Rarely able to problem solve and organize efficiently.



  • Often able to independently identify and prioritize major problems.

  • Often able to problem solve and organize efficiently.




  • Consistently able to identify and prioritize all major and most minor patient problems.

  • Consistently able to problem solve and organize efficiently.




  • Almost always able to identify and prioritize all major and minor problems.

  • Almost always able to problem solve and organize efficiently.




Management Skills: Includes order writing, initiative, practicality, and independence.

  • Does not offer an independent management plan or plan is unrealistic or illogical.

  • Rarely offers an independent management plan and/or plan is often unrealistic or illogical.

  • Often offers an independent management plan that is realistic and logical.

  • Consistently offers an independent management plan that is logical and realistic.

  • Almost always offers an independent management plan that is logical and realistic and includes preventative counseling.

Patient Centered Care (PCC): Skills including: 1.Elicits and negotiates agenda for the patient;

2. Elicits the patient’s perspective of their illness; and 3.Negotiates treatment plan with the patient



  • Does not elicit and negotiates agenda with patients.

  • Does not elicit the patient’s perspective of his/her illness.

  • Does not negotiate treatment plan with the patient.

  • Does not integrate biomedical and psychosocial perspective into care plan and patient management

  • Rarely elicits and negotiate agenda with patients.

  • Rarely elicits the patient’s perspective of his/her illness.

  • Rarely negotiates treatment plan with the patient.

  • Rarely integrates biomedical and psychosocial perspective into care plan and patient management.

  • Often elicits and negotiates agenda for the patient.

  • Often elicits the patient’s perspective of his/her illness.

  • Often negotiates treatment plan with the patient.

  • Often integrates biomedical and psychosocial perspectives into care plan and management of the patient.

  • Consistently elicits and negotiates agenda with the patient.

  • Consistently elicits the patient’s perspective of his/her illness.

  • Consistently negotiates treatment plan with the patient.

  • Consistently integrates biomedical and psychosocial perspectives into care plan and management.

  • Almost always elicits and negotiates agenda with the patient.

  • Almost always elicits the patient’s perspective of his/her illness.

  • Almost always negotiates treatment plan with the patient.

  • Almost always integrates biomedical and psychosocial perspectives into care plan and management.

COMMENTS:


  1. Patient Care Skills (Constructive criticism will not appear in the dean’s letter unless there is a pattern of similar behavior across other clerkship.)











PROFESSIONALISM SECTION For list of professionalism benchmarks see: http://www.fammed.washington.edu/predoctoral/clerkship/pro.htm


III. Interpersonal Relationships


Unacceptable

1


Below expectations

2


Meets Expectations

3


Exceeds Expectations

4


Exceptional

5


Communication Skills: Student’s ability to communicate with patients, families, colleagues, and staff; Includes ability to modify communication style and ability to listen and constructively resolves conflicts.

  • Does not communicate information effectively

  • Does not have an awareness to modify communication style and content to situation.

  • Unable to establish rapport.

  • Unable to listen and be silent.

  • Never culturally proficient.




  • Rarely communicates information effectively.

  • Rarely has an awareness to modify communication style and content to situation.

  • Rarely able to establish rapport.

  • Rarely able to listen and be silent.

  • Rarely culturally proficient.

  • Often communicates information effectively

  • Often modifies communication style and content to situation.

  • Often able to establish rapport.

  • Often able to listen and be silent.

  • Often culturally proficient.

  • Consistently communicates information.

  • Consistently modifies communication style and content to the situation.

  • Consistently able to establish rapport.

  • Consistently able to listen and be silent.

  • Consistently culturally proficient.




  • Almost always able to communicate information.

  • Almost always able to modify communication style and content to the situation.

  • Almost always able to establish rapport.

  • Almost always able to listen and be silent.

  • Almost always culturally proficient.




Relationships with Patients and Families: Includes courtesy, empathy, respect, compassion and understanding the patient’s perspective.


  • Disrespectful, indifferent, callus, discourteous or condescending.

  • Does not to solicit the patient‘s perspective.

  • Imposes own personal values on patient when in conflict with their own.

  • Violates HIPPA including patient confidentiality.

  • Inappropriate boundaries.

  • Exhibits behavior that is potentially harmful to patients

  • Rarely shows respect, empathy and compassion.

  • Rarely solicits the patient’s perspective.

  • Rarely respects patient’s values or imposes own personal values on patient when in conflict with their own.

  • Often demonstrates respect, empathy and compassion.

  • Often solicits the patient’s perspective.

  • Often respects the patient’s values, even when in conflict with their own.



  • Consistently demonstrates respect, empathy and compassion.

  • Consistently able to solicit the patient’s perspective.

  • Consistently respects the patient’s values even when in conflict with their own.




  • Almost always demonstrates respect, empathy and compassion.

  • Almost always able to solicit the patient’s perspective.

  • Almost always respects the patient’s values even when in conflict with their own.




Professional Relationships: Ability to work collaboratively with team members including faculty staff and other students; courteous and cooperative attitude. Maintains composure in times of stress.
  • Does not collaborate and/or establish appropriate relationships with team
  • Does not respect team members within and across specialties.
  • Not compassionate when interacting with team.
  • Does not clarify expectations or clinical responsibilities.

  • Inappropriate boundaries.

  • Disrespectful, indifferent, callus, discourteous or condescending.

  • Rarely collaborates and/or establishes appropriate relationships with team.

  • Rarely respects the roles of team members within and across specialties

  • Rarely is compassionate when interacting with team.




  • Often collaborates and establishes appropriate relationships with team.

  • Often recognizes and respects roles of all team members within and across specialties.

  • Often is compassionate when interacting with team.




  • Collaborates well with entire team.

  • Always recognizes and respects roles of team members within and across specialties.

  • Often compassionate when interacting with team.




  • Collaborates effectively with entire team and seeks to improve team function.

  • Always recognizes and respects roles of team members within and across specialties and works to improve team cohesion..

  • Consistently compassionate when interacting with team




COMMENTS:(Constructive criticism will not appear in the dean’s letter unless there is a pattern of similar behavior across other clerkship.)







PROFESSIONALISM SECTION For list of professionalism benchmarks see: http://www.fammed.washington.edu/predoctoral/clerkship/pro.htm

IV. Personal Characteristics



Unacceptable

1


Below Expectations

2


Meets Expectations

3


Exceeds Expectations

4


Exceptional

5


Educational Attitudes: Includes active participation in learning, self-reflection and responsiveness to feedback and provides respectful and constructive feedback

  • Does not do what is required.

  • Does not respond appropriately to feedback.

  • Does not reflect on their own knowledge base.

  • Does not participate in educational experiences

  • Is not actively engaged in learning.

  • Argumentative or hostile with feedback.

  • Values self above others, sense of entitlement.

  • Engages in destructive competition

  • Feedback provided to others is not respectful.




  • Rarely does what is required.

  • Rarely responds appropriately to feedback.

  • Rarely reflects on their own knowledge base.

  • Rarely participates in educational experiences

  • Rarely is actively engaged in learning.




  • Often does what is required.

  • Often responds appropriately to feedback.

  • Often able to reflect on their own knowledge base.

  • Often participates in educational experiences.

  • Often is actively engaged in learning.




  • Does what is required and often seeks additional learning opportunities beyond required level.

  • Consistently seeks feedback and responds appropriately.

  • Consistently able to reflect on their own knowledge base.

  • Consistently participates in educational experiences.

  • Consistently and actively engaged in learning.




  • Actively participates in all activities.

  • Actively seeks feedback and responds appropriately.

  • Initiates self-assessment and teaches others.

  • Almost always participates in educational experiences.

  • Almost always is actively engaged in learning. Asks insightful questions, motivates others, and demonstrates leadership with individuals and in-group settings.




Dependability and Responsibility: Includes attendance, preparation, and personal appearance. Maintains personal honor and integrity


  • Frequently late without a legitimate reason or unprepared

  • Does not follow through with assigned tasks.

  • Not trusted to work independently.

  • Dishonest in any way.

  • Does not maintain appropriate appearance.

  • Absent without an excuse

  • Erratic or unpredictable behavior.

  • Occasionally late or unprepared.

  • Rarely follow through with assigned tasks.

  • Rarely trusted to work independently

  • Always on time and prepared.

  • Often follows through with assigned tasks.

  • Often trusted to work independently and knows limits and asks for help when needed.




  • Always on time and prepared.

  • Follows through with assigned tasks and often volunteers additional effort to follow through with patient care.

  • Consistently trusted to work independently and knows limits and asks for help when needed.

  • Always on time and prepared for required and optional activities.

  • Follows through with assigned tasks and consistently volunteers additional effort to follow through with patient care.

  • Almost always trusted to work independently and knows limits and asks for help when needed.



COMMENTS: (Constructive criticism will not appear in the dean’s letter unless there is a pattern of similar behavior across other clerkship.)







FAMILY MEDICINE CLERKSHIP FEEDBACK AND EVALUATION FORM


Time Spent with Student










Little or no contact




























Sporadic and superficial




























Infrequent but in-depth




























Frequent and in-depth




Overall Assessment of Performance.










Unacceptable level of performance (Fail)




























Below expected performance for level (Marginal)




























At expected performance for level (Pass)




























Exceeds expected performance for level (High Pass)




























Exceptional (Honors)



















Evaluator Concern










Check if there is/are area(s) of particular concern, but failing grade is not

given. Areas receiving “Below Expectations“ should be considered as potential areas of concern. Please describe the area of concern or contact clerkship site coordinator for details.















_______

_________





_________






Evaluator Signature: _______________________________________________________________ Date: _________________________________
Revised 6/12/08 tk


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