UTCOM
M3 Internal Medicine Core Clerkship
Student
Evaluation Forms
I.
Midpoint Evaluation Form
Completion
of this form by your Medicine Attending Physician is intended to
provide you with useful feedback, constructive criticism, and recommendations
for improvement. This form should be completed at the midway point
during each month-long clerkship assignment. It is the student’s
responsibility to obtain this necessary inform. This form and its
comments will not be used in any way by the clerkship director during
the determination of your final grade. This form should help you
improve your performance so that you may do your very best.
Student
Strengths |
Student
Weaknesses |
Recommendations
for Improvement
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3.
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5.
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Attending
Signature______________________________ Date: _________________
Attending
Name_______________________________________________ (Please
Print)
Student
Signature_______________________________ Date__________________
Student
Name_________________________________________________ (Please
Print)
II.
Blue Card—H&P checklist (to be performed once during clerkship,
and is to be filled out by the intern, resident, or attending)
History:
HPI:
PMHx:
Hosp., Surgery, Injury:
Medications
and Allergies:
Immunizations:
Family
History and Social:
Diet
and ROS:
Physical
Exam:
General:
Vital signs:
Orthostatic Vital Signs
Head
and Neck:
Cardiovascular:
Lungs:
Abdomen:
GU:
Rectal:
Extremeities
and Back:
Neurologic:
Skin:
III.
Summative form
M3
MEDICINE CORE CLERKSHIP STUDENT EVALUATION FORM
Be
sure to obtain housestaff input when evaluating this student.
STUDENT
NAME:___________________________________ ( KNOXVILLE
)
DATE:
BLOCK:
Check
the descriptors that best describe this student.
I.
Skills
A.
Observed history taking and physical exam:
(
) Extremely disorganized or ( ) does not follow up leads obtained
in history or exam or ( ) missing major segments or ( ) no chronology
to history
(
) Somewhat disorganized or ( ) misses some leads from history and
exam or ( ) displays some technical inadequacies or ( ) H&P
doesn’t support assessment or plan
(
) Rarely disorganized or ( ) generally completes H&P with a
few lapses or ( ) patient problem identification adequate and logical.
(
) Careful attention to leads and ( ) H&P very accurate, organized
and detailed and ( ) H&P clearly supports logical assessment
with management plan
B.
Progress notes:
(
) Careless in recording or ( ) disorganized or ( ) written late.
(
) Sometimes superficial or ( ) frequently lacks ability to organize
information or analyze new data or ( ) has difficulty with assessment
and plan
(
) Record keeping is consistently legible and appropriate and ( )
data recording, problem analysis, therapeutic program are organized
and complete with rare omissions
(
) Uniformly accurate in recording and interpreting new findings
and ( ) timely with an exhaustive problem list and ( ) expands database
to support differential diagnosis and patient management
C.
Oral case presentations and assigned talks:
(
) Extremely disorganized or ( ) often not prepared with background
information for assigned talks or rounds or ( ) overly dependent
on written prompters
(
) Acceptable delineation of primary problems but with frequent “holes”
in characterization, chronology, and diagnostic information
(
) Presentations are consistently solid – mostly focused, good chronology,
easy to follow, accurate, organized with few lapses.
(
) Outstanding – early, clear delineation of primary problems; excellent
characterization and ( ) accurate chronology of key events in patient’s
illness
COMMENTS:
________________________________________________________________________________________________
II.
Clinical knowledge and problem solving
A.
Fund of knowledge and understanding of disease mechanisms:
(
) Overall knowledge base very limited or unknown or ( ) often not
prepared for assigned talks or rounds.
(
) Fair knowledge base but poor understanding of disease mechanisms
(
) Solid fund of knowledge and understanding of disease mechanisms
with rare gaps
(
) Outstanding fund of knowledge and understanding of disease mechanisms
beyond current level of training
B.
Clinical application:
(
) Demonstrates very poor ability to clinically apply knowledge or
( ) makes dangerous recommendations
(
) Occasionally shows poor judgment or ( ) shows some abilities in
clinical application but hampered by poor fund of knowledge or
(
) displays little thought to prevention
(
) Consistently demonstrates ability to apply solid knowledge base
in most clinical situations
(
) Outstanding ability to integrate history, physical exam, and lab/study
data in the identification, prioritization, and
(
) recommends preventive interventions
C.
Problem solving:
(
) Completely lacks the ability to problem solve or ( ) comes up
with bizarre conclusions
(
) Displays some difficulty in ability to problem solve or ( ) frequent
difficulty prioritizing
(
) Consistently reflects ability to problem solve with occasional
lapses
(
) Outstanding ability to integrate history, physical exam, and lab/study
data in the identification, prioritization, and
(
) solving of clinical problems
COMMENTS:
_______________________________________________________________________________________________________
III.
Professional and personal attributes
A.
Professional attributes and responsibilities:
(
) Cannot be relied upon or ( ) frequently unavailable when needed
or ( ) suggestive or inappropriate attire or
(
) erratic attendance and punctuality or ( ) socially aggressive
(e.g., sandbags others, arrogant)
(
) Occasional inappropriate behavior; too intimate, poor confidentiality,
poor choice of language, etc. or
(
) passive, peripheral, needs reminders to fulfill ward responsibilities
(no patient ownership)
(
) Reliable in fulfilling responsibilities as a member of the ward
team and in the delivery of patient care with rare lapses
(
) Outstanding in attendance, dependability and punctuality and (
) integral team member; assumes high levels of patient care responsibilities
and ( ) assumes true patient ownership.
B.
Self-improvement and adaptability:
(
) Completely unaware of own inadequacies or ( ) always makes excuses
or ( ) resistant or defensive in accepting criticism
(
) Makes an effort to change when criticized even if unsuccessful
or ( ) reads just enough to get by or ( ) has difficulty coping,
seems
stressed out
(
) Able to adequately effect change when criticized or ( ) reads
about patients
(
) Outstanding at soliciting and receiving criticism with interest
and grace and ( ) makes an extra effort to learn about patients’
problems with extensive supplemental reading
C.
Information management:
(
) Little evidence student reads or ( ) unable to provide appropriate
literature to support patient care
(
) Relies almost solely on texts for information or ( ) doesn’t seem
to understand study design or statistical methods or
(
) unable to access on-line medical information to support decision
making
(
) When faced with a clinical problem, frequently uses various resources
to develop and implement a plan of investigation
(
) Displays extensive understanding or use of EBM, scientific and
statistical method, critical evaluation of the literature and use
of various information technologies
D.
Relationships with patients:
(
) Frequently insensitive to patient’s feelings and wishes or ( )
condescending or arrogant or ( ) insensitive or disrespectful of
cultural differences
(
) Sometimes has difficulty establishing rapport with patients or
communicating with them
(
) Relates well to most patients and family members, with few exceptions
or ( ) shows empathy, compassion and respect or
(
) displays effective listening skills
(
) Outstanding in putting patient and/or family members at ease and
appropriately communicating medical information to them and
(
) appreciates and respects cultural differences
E.
Interpersonal relationships with other members of health care team:
(
) Friction or conflict with health care providers or ( ) inappropriately
oversteps or questions authority or ( ) makes minimal effort to
integrate into the team
(
) Sometimes has difficulty relating well to health care team members
(
) Relates well to most of the health care team members or ( ) solidly
integrated into the team
(
) Outstanding in respecting the feelings, needs, wishes and rights
of all health care team members and ( ) highly integrated into the
team structure
COMMENTS:
_______________________________________________________________________________________________________________
Clerical
Use Only
Block
grade _______
Exam
Score_______
Final
Grade_______
__________________________________________________
Discussed with student (Yes / No)
Signature
of Evaluator
___________________________________________________
________________________________
Printed
Name of Evaluator Residents
Return
Form To:
Fax:
(901) 545-6704
Phone:
(901) 545-8248
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