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OBG 430 – OBGYN CLERKSHIP STUDENT EVALUATION
UC DAVIS SCHOOL OF MEDICINE
Subject:
Evaluator:
Site:
Period:
Dates of Activity:
Evaluation Type: MEDICAL STUDENT
HISTORY
Insufficient
Contact
0
FAIL:
Does not understand the technique of
doing a history. History with glaring
inaccuracies or areas left out despite
significant prompting/demonstration.
History superficial or done by rote and not
directed towards the patient’s problems.
1
2
3
PASS:
(majority of 3rd year students expected to be
5)
History complete with some
prompting/assistance.
4
5
6
HONORS:
top 20% of students
Consistently exceptionally precise
and reliable history: asking all
pertinent positives and negatives
and tailored to the developmental
age, type of visit. Leaving out
extraneous questions.
7
8
9
COMMENTS:
PHYSICAL EXAM
Insufficient
Contact
0
FAIL
Does not understand the technique of
doing a physical exam. Physical exam
with glaring inaccuracies or areas left out
despite significant prompting/
demonstration. Physical exam superficial
or done by rote and not directed towards
the patient’s problems.
1
2
3
PASS:
(majority of 3rd year students expected to be
5)
Physical exam complete with some
prompting/assistance.
4
5
6
HONORS:
top 20% of students
Consistently exceptionally precise
and reliable physical exam: all
pertinent positives and pertinent
negatives included. Minimizing
extraneous parts of the physical
exam.
7
8
9
COMMENTS:
ORGANIZATION
FAIL
Insufficient
Contact
0
Unable to organize the parts of the history
and physical exam. Done by rote, not
directed towards patient's problems.
1
2
3
COMMENTS:
OBG 430 – Medical Student Evaluation - CONFIDENTIAL
PASS:
(majority of 3rd year students expected to be
5)
Able to organize the parts of the history and
physical in a systematic way.
4
5
6
HONORS:
top 20% of students
Superior ability to perform a target
or complete history and physical
exam in a systematic way. Always
identified the subtle points that are
appropriate for patient’s problems.
7
8
9
RECORDING
FAIL
Insufficient
Contact
0
Write-ups and progress notes do not
reflect what is happening with the patient
- major discrepancies between the
student's assessment/plan and that of the
attending even after discussing plan with
attending. Write-ups and progress notes
are disorganized. Write-ups and progress
notes are not done promptly.
1
2
3
PASS:
(majority of 3rd year students expected to be
5)
Write-ups and progress notes accurately
reflect plan assessment and plan for the
patient with assistance/modification by the
intern/resident.
4
5
6
HONORS:
top 20% of students
Consistently superior write-ups and
progress notes which reflect an upto-the-minute assessment and plan
for the patient. Well-organized.
7
8
9
COMMENTS:
ORAL PRESENTATIONS
FAIL
Insufficient
Contact
0
Unable to communicate relevant clinical
information. Presentations are rambling,
poorly organized, or confused. Requires
frequent prompting to present pertinent
information.
1
2
3
PASS:
(majority of 3rd year students expected to be
5)
Able to communicate clinical information with
some prompting.
4
5
6
HONORS:
top 20% of students
Consistently well-organized,
focused presentations that include
only pertinent positives and
pertinent negatives - leaves out
extraneous information.
7
8
9
COMMENTS:
FUND OF KNOWLEDGE
FAIL
Insufficient
Contact
0
Unable to recall or apply basic science
knowledge to clinical problems.
Fragmentary or poorly organized clinical
knowledge.
1
2
3
PASS:
(majority of 3rd year students expected to be
5)
Able to apply basic science for most
patients.
4
5
6
HONORS:
top 20% of students
Exceptional ability to recall and
apply basic science to clinical
problems. Medical/clinical
knowledge is extensive and well
applied.
7
8
9
COMMENTS:
UNDERSTANDING OF DISEASE MECHANISMS
PASS:
(majority of 3rd year students expected to be
5)
FAIL
Insufficient
Contact
0
Has difficulty connecting pathophysiologic
mechanisms with clinical syndromes.
1
2
3
COMMENTS:
OBG 430 – Medical Student Evaluation - CONFIDENTIAL
Solid knowledge of pathophysiology,
diagnosis and therapy.
4
5
6
HONORS:
top 20% of students
Superior knowledge of
pathophysiology, diagnosis and
therapy.
7
8
9
CLINICAL PROBLEM SOLVING SKILLS
FAIL
Insufficient
Contact
Unable to reason problems through
despite repeated prompting/suggestions.
Unable to identify key patient problems.
Unable to use common symptoms or
findings on physical examination to arrive
at a differential diagnosis. Differential
diagnosis list either too broad or too
narrow.
0
1
2
3
PASS:
(majority of 3rd year students expected to be
5)
Able to come up with some reasonable
suggestions for differential diagnosis and
initial evaluation. .
4
5
6
HONORS:
top 20% of students
Consistently superior ability identify
and prioritize patient’s problems
(major, minor) and to justify
differential diagnosis and initial
evaluation. Takes into account a
test’s risks and benefits.
7
8
9
COMMENTS:
PRACTICE-BASED LEARNING (SELF-EDUCATION) SKILLS
HONORS:
top 20% of students
FAIL
Insufficient
Contact
Has not read about their patient’s
diseases. Relies solely on other medical
staff (interns, residents, attendings,
consultants) to spoon-feed them
information on their patient and their
diseases.
0
1
2
3
PASS:
(majority of 3rd year students expected to be
5)
Reads about their patient's diseases in the
major OBGYN textbooks or other appropriate
(online) resources and/or medical literature.
4
5
6
Intellectually curious. Consistently
forms a relevant clinical question for
the care of their patient (without
prompting by the attending) and
consistently conducts an effective
search of the medical literature
(including major textbooks and
journals) to help develop a
differential diagnosis, diagnostic
plan, or management plan relative
to the care of your patients.
Superior ability to conduct an
effective search of the medical
literature and effectively synthesize
and apply what you find in your
literature search to the care of your
patients and share the key points
with the team.
7
8
9
COMMENTS:
INTERPERSONAL & COMMUNICATION SKILLS WITH PATIENTS AND FAMILIES
HONORS:
top 20% of students
FAIL
Insufficient
Contact
Often disrespectful, discourteous or
indifferent. Unable to establish even
minimally effective therapeutic
relationships with patients and families.
Does not demonstrate ability to build
relationships through listening, narrative
or nonverbal skills.
0
1
2
3
COMMENTS:
OBG 430 – Medical Student Evaluation - CONFIDENTIAL
PASS:
(majority of 3rd year students expected to be
5)
Able to form an effective therapeutic
relationship with patients and families.
Demonstrates respect for patients. Able to
discuss basic medical information in terms
understandable to patients and families with
some guidance.
4
5
6
Establishes a highly effective
therapeutic relationship with
patients and families. Demonstrates
excellent relationship building
through listening, narrative and nonverbal skills. Excellent education
and counseling of patients, families
and colleagues. Able to discuss
medical information in terms
understandable to patients and
families, being sensitive to the
family’s social and cultural
backgrounds. Encourages
collaboration in the treatment plan.
Always 'interpersonally engaged.'
7
8
9
SYSTEM BASED PRACTICE
FAIL
Insufficient
Contact
Ineffective not reliable and disorganized
organization in working with the health
care team and guiding patient
management. Ineffective in health team
based activities. Passive in patient
management. Unable to navigate or
access information through EMR.
0
1
2
PASS:
(majority of 3rd year students expected to be
5)
A cooperative, organized, and effective
member of the team. Handles day-to-day
responsibilities well. Able to approach and
execute a plan. Able to utilize resources,
electronic medical record, discharge
planning.
3
4
5
HONORS:
top 20% of students
A highly effective member of the
team. Demonstrates independence
in accessing and utilizing outside
and available resources. Such as
EMR discharge planners
consultants, communicating with
other hospitals/care givers. Takes
ownership of their patients and the
care they receive: functions at the
level of junior house officer.
6
7
8
9
COMMENTS:
PROFESSIONALISM
FAIL
Insufficient
Contact
Does not show up. Consistently late for
clinic/rounds. Does not read required
materials. Lack of follow through on labs
or other aspects of patient care.
Uninterested in learning. Resists/ignores
feedback. Lacks respect, compassion,
integrity, honesty. Unable to function as a
team player. Unable to demonstrate
collegiality and respect for members of
the health care team. Fails to
acknowledge own errors.
0
1
2
3
PASS:
(majority of 3rd year students expected to be
5)
Able to function as part of the health care
team. Often demonstrates respect,
compassion, integrity, honesty. Prompt,
adequately prepared for activities. Follows
through on patient responsibilities. Positive
attitude toward active learning: Demonstrates
intellectual curiosity, initiative, responsibility,
reliability, and respect for peers, colleagues,
and teachers. Responds to feedback about
performance.
4
5
6
COMMENTS:
PROFESSIONALISM CONCERNS (mark any that apply)
Tardiness – Arriving late without notifying appropriate individuals
Lack of Availability – Occasions of being unavailable for required clinical responsibilities
Missed Deadlines – Difficulty meeting deadlines or following through
Unpreparedness – problems being prepared or participating in discussion
Not a Team Player – Difficulty working as a team
Resistance to feedback
Not recognizing limitations and not calling upon assistance of others
Lack of respect or civility towards others
Breach of Confidentiality – Lapses in patient confidentiality
Lack of Compassion – Problems/lapses in addressing fears and suffering of patients
Prejudice – Expresses behavior showing bias towards groups of people
OBG 430 – Medical Student Evaluation - CONFIDENTIAL
HONORS:
top 20% of students
Always demonstrates respect,
compassion, integrity, honesty.
Always prompt and comes prepared
beyond expectations for activities.
Always considers needs of patients,
families, colleagues. Volunteers for
additional patient care
responsibilities. Teaches/role
models responsible behavior. Total
commitment to self-assessment.
Willingly acknowledges errors.
Actively seeks and responds readily
to feedback about performance.
7
8
9
If you would recommend this student for commendation for professionalism, please make comments to
support this recommendation:
STUDENT’S OVERALL CLINICAL COMPETENCE
Insufficient
Contact
0
1-3
Unsatisfactory
1
2
4-6
Satisfactory
3
4
5
7-9
Superior
6
7
8
9
SUMMATIVE COMMENTS – FOR DEAN’S LETTER
FORMATIVE COMMENTS and Recommendations– FOR STUDENT & ADVISOR, NOT DEAN’S LETTER
CONCERNS ABOUT STUDENT – Do you have any concerns that this student might have
personal and/or psychosocial problems that might make him/her unable to function
effectively as a physician in training?
TIME SPENT WITH STUDENT
Minimal/Superficial
(0-1 day)
Moderate
(2-5 days)
YES
NO
Frequent/In-depth
(> 5 days)
DISCUSSION WITH STUDENT – I discussed the above evaluation feedback with the student
YES
NO
FEEDBACK DURING ROTATION – I gave the student feedback during the rotation
YES
NO
Signature __________________________________ Date _______________________________________
Email Address __________________________________________________________________________
Return this form to:
Ida Shunk, OB/GYN Clerkship Program Representative
Medical Education
4610 X Street, Sacramento, CA 95817
Fax: 916-734-4506
Phone: 916-734-3531
OBG 430 – Medical Student Evaluation - CONFIDENTIAL