Download Requirements of the Rotation 4-5

COLLEGE OF PHARMACY
Preceptor Syllabus
PHAR 7020 Hospital Pharmacy Practicum I
2008-2009
1
TABLE OF CONTENTS
Accepted Holidays & Dates for P-4 Meetings/Exams
3
Orientation to the Practice Site
4
Requirements of the Rotation
4-5
Attendance, Punctuality and Absences
4-5
Student Rotation Portfolio
5
Learning Objectives for the Rotation
5-7
Required Readings for the Student
8
Learning Objectives for the Exam
9-11
Medications for the Exam
12
Evaluation of the Pharmacy Student
13
Grading
13
APPENDICES
A. Preceptor Responsibilities
14-15
B. Preceptor Evaluation Form
16
C. Site Evaluation Form
17
D. Hospital Pharmacy Practicum Check Sheet
18-19
E. OU/SWOSU Experiential Evaluation Form
20-28
2
DOCTOR OF PHARMACY STUDENT PRACTICUMS
The Doctor of Pharmacy Program at the University of Oklahoma College of Pharmacy is an
ACPE-accredited entry-level Doctor of Pharmacy Program. The practicum (rotation) program
consists of the 9 one-month experiences listed below, scheduled between June 2008 and May
2009.
Ambulatory Care Clinical Practicum
Community Pharmacy Practicum
Adult Medicine/Acute Care Clinical Practicum
Institutional Pharmacy Practicum
*Selective/Elective Practicums
2 months
1 month
1 month
1 month
4 months
* Selective/Elective experiences can include additional months of ambulatory care, acute care,
community, or institutional practicums depending on availability. Specialty areas such as home
health care, compounding, drug information, managed care, administrative pharmacy,
research, long-term care, or other experiences can also fulfill selective/elective requirements.
Rotation attendance, required examinations, and meetings
Unless otherwise instructed, students begin a practicum on the 1st working day and end on the
last working day of the month. Students are required to attend all working days of the month or
as arranged by the preceptor(s)-of-record with approval of the Director of Experiential Education.
Exceptions to this include observed University holidays, unless otherwise instructed by the
preceptor-of-record in conjunction with the Director of Experiential Education (see pages 4 and 5
for more details). Rotation credit is a minimum of 160 hours of contact per month. For the 20082009 academic year, observed holidays, student practicum course meetings/examinations (room
101 in OKC, 1D28 in Tulsa unless otherwise instructed), and other special events include (subject
to change):
Community/Hospital exams
Independence Day
Community/Hospital exams
Community/Hospital exams
Labor Day
Community/Hospital exams
Community/Hospital exams
P-4 class meeting
Community/Hospital exams
Thanksgiving Holiday
Community/Hospital exams
December Holiday
New Years Holiday
Martin Luther King Day
Community/Hospital exams
Community/Hospital exams
P-4 class meeting
Community/Hospital exams
Community/Hospital exams
P-4 class meeting
Memorial Day
Community/Hospital exams
*
Senior Placement Conference(s)
Graduation Convocation
*
June 26, 2008, 3 - 4 p.m.
July 4, 2008
July 31, 2008, 3 - 4 p.m.
August 28, 2008, Time TBA
September 1, 2008
September 25, 2008, Time TBA
October 30, 2008, Time TBA
October 30, 2008, Time TBA
November 25, 2008, Time TBA
November 27-28, 2008
December 23, 2008, Time TBA
December 25, 2008
January 1, 2009
January 19, 2009
January 29, 2009, Time TBA
February 26, 2009, Time TBA
February 26, 2009, Time TBA
March 26, 2009, Time TBA
April 30, 2009, Time TBA
April 30, 2009, Time TBA
May 25, 2009
May 28, 2009, Time TBA
Fall 2008, Spring 2009 (dates pending)
June 2009 (date pending)
permission to attend placement conference(s) during scheduled interview times is required
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I. Orientation to the Practice Site
Practice site hours: ______________________________________________
Lunch policy: _____________________________________________________
The preceptor should review the following with the student on the first day of the
rotation:
1.
2.
3.
4.
5.
6.
7.
Goals, objectives, and minimal competency requirements of the rotation.
Dates for the mid-point and final evaluations.
Rotation hours and attendance policy.
Dress code for the facility.
Tour of the facility.
Introduction to key members of the facility and a brief description of their duties.
Obtain an identification badge from Human Resources and complete facility
orientation requirements (if applicable).
8.
Review facility policies and procedures.
9.
Introduction to the Pharmacy Information System.
10. Review and discuss the student’s rotation portfolio.
11. Indicate the location of reference materials available to students.
12. Review the contents of this manual. The students will have access to a student
version and project guidelines.
II. Requirements of the Rotation
A. Attendance and Maintenance of the Student Portfolio
Unless otherwise instructed, students begin a practicum on the 1st working day and
end on the last working day of the month. Students are required to attend all working
days of the month or as arranged by the preceptor(s)-of-record. Exceptions to this
include observed University holidays, unless otherwise instructed by the preceptorof-record in conjunction with the Director of Experiential Education. Rotation credit is
a minimum of 160 hours of contact per month.
Students must attend all working days of each rotation month. Tardiness will not be
tolerated. The student may be required by the preceptor or Director of Experiential
Education to complete an extra rotational day for each episode of tardiness.
Repeated tardiness on any single or between multiple rotation(s) may result in
dismissal from a practicum and an unsatisfactory grade (0%), with subsequent reenrollment in the course. Individuals unable to attend any portion of a rotation must
provide written justification for their absence unless otherwise specified. In cases of
illness, these should preferably be signed by the appropriate health professional
treating the individual. The student must seek approval from the preceptor for
anticipated absences prior to the missed session and unexpected absences as soon
as is practical. Acceptance of the excuse will be at the discretion of the individual
instructor and Director of Experiential Education. All absences from rotations
conducted by adjunct faculty must be communicated via telephone by the student to
the Director of Experiential Education on the day of the absence. E-mail is not an
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acceptable form of communication to obtain an excused absence. Unexcused
absences will not be tolerated.
An unexcused absence may result in an
unsatisfactory grade (0%), and require subsequent re-enrollment in the course.
Excused absences will require that missed rotation time be completed “after hours”
or on weekends, unless otherwise directed.
Students must maintain a portfolio and present it to assigned preceptors on the first
day of each rotation, and/or as required. Student portfolios must be completed as
specified and submitted for verification prior to college-reporting of experiential hours
required for licensure. Though patient-related activities and information are required
for the portfolio, students must safeguard privacy and not include patient name(s).
B. The student must fulfill learning objectives (pages 5 - 7) and complete a related
check sheet. The check sheet is supplied to the student by the college and should
be kept in the student’s portfolio following completion and verification by preceptor
signature.
C. The student must pass the required exam administered by the College (readings and
objectives on pages 7 - 12). The student is supplied a copy of the objectives and
access to the readings. A score of at least 70% will be required on the exam to
pass the rotation, or the student must repeat an entire hospital rotation. The
College will notify the student and preceptor of the exam date and time.
III. Learning Objectives for the Rotation
1. PATIENT CARE: The student will provide patient care by:
A. Demonstrating proper oral and written communication skills by:
1. Taking patient medication histories.
2. Providing patient counseling.
3. Accurately providing drug information to other health professionals.
B. Utilizing a medication record system to detect:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
A patient's history of adverse effects.
Potential unwarranted medication changes.
Potential quantitative misuse of medications.
Duplication of medications.
Potential unwanted additive effects of medications.
Inappropriate dose, route, schedule, or dosage form.
Possible adverse effects.
Drug-drug and drug-food interactions.
Drug-disease interactions
Possible irrational therapeutics.
C. Demonstrating the application of pharmacokinetic principles to patient care.
D. Establishing patient outcome parameters and monitoring those parameters.
5
2. DRUG PREPARATION AND DISTRIBUTION: The student will have a working
knowledge of the drug preparation and distribution systems of the institution and be
able to:
A. Interpret medication and IV admixture requests, determine their accuracy,
completeness, and legality, and prepare an appropriate label for the medication
according to the institution's guidelines.
B. Describe controlled substance laws and the institution's procedure for dispensing
controlled substances.
C. Participate in the institution's medication delivery system including:
1. Reviewing orders for appropriateness against the patient profile, making
additions to, and deletions from this record, and understanding the steps
necessary to clarify a questionable order.
2. Accurately filling unit dose orders.
3. Accurately filling bulk medication orders including selecting the appropriate
container.
4. Demonstrating proper aseptic technique and the ability to extemporaneously
prepare admixture solutions.
5. Recalling common IV incompatibilities and reference sources for information
concerning parenteral drug and solution administration, stability, and
compatibility.
D. Demonstrate the ability to accurately perform pharmacy calculations. (i.e., IV
admixtures, drip rates, and extemporaneously compounded products.)
E. Describe the hospital's procedure for dealing with outpatient prescriptions.
F. Demonstrate the use of auxiliary labeling to aid the nurse in administering
medications and intravenous admixtures.
G. Participate in the manufacturing and or repackaging of a pharmaceutical product
including tracing the controls and records that should be used to ensure the
quality of the finished product.
H. Discuss the application of satellite pharmacy services, drug information centers,
and clinical services to institutional practice.
3. PHARMACY MANAGEMENT AND ADMINISTRATION:
The student will
demonstrate an understanding of the administrative responsibilities involved in
operating a hospital pharmacy department by:
6
A. Describing and/or attending pharmacy related hospital committee meetings and
describing the purpose, function, and line of responsibility of each - especially the
Pharmacy and Therapeutics and Quality Assurance committees.
B. Describing the lines of communication and shared responsibilities of other health
related areas that interact with the pharmacy department.
C. Explaining some Policies and Procedures of the hospital and discussing
standards and guidelines of the Joint Commission on Accreditation of Healthcare
Organizations.
D. Identifying the role and activities of pharmacy technicians.
E. Identifying the organizational structure of the pharmacy department.
4. DRUG POLICY MANAGEMENT: The student will demonstrate familiarity with
different drug management policies in hospital pharmacy by:
A. Participating in and/or describing the Drug Use Evaluation process taking place
in the institution.
B. Describing the institution's policies and procedures for handling investigational
drugs.
C. Identifying the procedure for reporting and documenting medication errors and
adverse drug reactions and explaining the steps in the institution's ADR reporting
program.
D. Identifying the procedure for the handling of "meds from home" and drug
samples.
E. Describing the institution's formulary system.
F. Describing the difference between therapeutic and generic equivalence and how
this affects the formulary.
G. Describing any current or anticipated pharmacoeconomic issues.
5. PURCHASING AND INVENTORY: The student will be able to demonstrate an
understanding of purchasing and inventory and their impact upon general operations
regarding areas such as budgeting, bookkeeping procedures, pricing policy, and
application of computer systems by:
A. Explaining the inventory control activities including ordering, checking, stocking,
and physical inventory control.
B. Discussing procedures involved in ordering controlled substances.
C. Discussing the procedure for the handling of manufacturer recalls of medications.
D. Describing the procedure for handling of non-formulary or non-stocked drug
requests.
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IV. Required Readings and References for the Student
References 4 and 5 can be obtained on-line at http://pharmacy.ouhsc.edu/coursenotes/
P-4, PHAR 7020, Hospital Practicum (password is hospital).
1. Flanders B, Sigler J, eds. Pharmacy Drug Cards, 23rd Edition, Lawrence, KS, Sigler &
Flanders, Inc., 2007.
2. Whitney J. Parenteral Nutrition. In: Boh LE, ed. Pharmacy Practice Manual: A Guide
to the Clinical Experience. 2nd edition. Philadelphia: Lippincott, Williams & Wilkins,
2001. p. 460 – 506.
3. Lam YWF, Chan CYJ. Clinical Pharmacokinetics. In: Boh LE, ed. Pharmacy Practice
Manual: A Guide to the Clinical Experience. 2nd edition. Philadelphia: Lippincott,
Williams & Wilkins, 2001. p. 538-78.
4. Vogel F. Intravenous/oral sequential therapy in patients hospitalised with communityacquired pneumonia: Which patients, when, and what agents? Drugs 2002; 62:309-17.
5. Antibiotic review for PHAR 7020 (with learning objectives included in the document).
6. Lutfiyya MN, Henley E, Chang LF. Diagnosis and treatment of community-acquired
pnemonia. Am Fam Physician 2006;73:442-50. Available from: URL:
http://www.aafp.org/afp/20060201/442.html
7. Mandell LA, Wunderink RG, Anzueto A, Bartlett JG, Campbell GD, Dean NC, et al.
Infectious Diseases Society of America/American Thoracic Society consensus
guidelines on the management of community-acquired pneumonia in adults. Clinical
Infectious Diseases 2007, Mar 1; 4 Suppl 2:S27-72. Available from: URL:
http://www.journals.uchicago.edu/doi/pdf/10.1086/511159
8. USP General Chapter 797 Pharmaceutical Compounding Sterile-Preparations. Available
from: URL: http://www.usp.org/pdf/EN/USPNF/generalChapter797.pdf
9. The Joint Commission National Patient Safety goals. Available from: URL:
http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/08_hap_npsg
s.htm
10. Joint Commission “Do Not Use” list Available from: URL:
http://www.jointcommission.org/NR/rdonlyres/2329F8F5-6EC5-4E21-B93254B2B7D53F00/0/06_dnu_list.pdf
11. Oklahoma Pharmacy Lawbook 2008 (unofficial). Available from: URL:
http://www.ok.gov/OSBP/documents/law08.pdf
12. Oosterheert JJ, Bonten MJ, Schneider MM, Buskens E, Lammers JW, Hustinx WM, et
al. Effectiveness of early switch from intravenous to oral antibiotics in severe community
acquired pneumonia: multicentre randomized trial. BMJ 2006 Dec 9; 333 (7580):1193.
Available from: URL: http://www.bmj.com/cgi/reprint/333/7580/1193
8
V. Learning Objectives for the Exam (based on required readings, as applicable)
For the selected medication products listed on page 12, students will be able to list, identify
and/or select:



Brand and generic name
Dosage forms
Classification
o
o









general class listed at the bottom right corner of pharmacy drug card
chemical class if listed under pharmacology section of pharmacy drug card
FDA-approved indications
Dosage information as specified
Pharmacology
Pharmacokinetics (if specified)
Contraindications
Adverse effects
Drug interactions
Patient consultation information
Other information as specified
1. PATIENT CARE: The student should be able to:
Demonstrate the application of pharmacokinetic principles to patient care (reference 3).


Identify and/or define the meaning of “steady-state” concentrations
Identify and/or list the importance of “peak” sampling after drug distribution is complete
in terms of accurately reflecting the target drug site.
 Recognize and/or list the minimum amount of time that should elapse after the end of an
intravenous infusion prior to sampling a peak concentration for aminoglycosides and
vancomycin
 Identify and/or list (at least 3) appropriate indications for therapeutic drug monitoring
 Recognize and/or list target peak and trough concentrations for gentamicin
 Recognize and/or describe the practice of administering the entire daily dose of an
aminoglycoside such as gentamicin, including expected peak/trough concentrations vs.
traditional dosing
 Recognize and/or list target peak and trough concentrations for vancomycin
 Identify and/or list symptoms associated with “red man syndrome” related to
vancomycin, as well as procedures to minimize it’s occurrence
 Recognize and/or list toxicities associated with elevated peak and/or trough levels of
aminoglycosides (i.e. gentamicin) and vancomycin
Understand pharmacotherapy-related issues associated with community-acquired
pneumonia (CAP)
(reference 6).

Recognize and/or list the signs and symptoms, risk factors, and bacterial etiologies of
CAP
9


Recognize patterns of resistance to antibiotics and the influence on drug selection
Given a patient case, select or recommend appropriate antibiotic therapy
( reference 7)






Identify appropriate empiric antimicrobial therapy for outpatient treatment of community
acquired pneumonia in a previously healthy patient with no risk factors for drug-resistant
S. pneumonia infection
Identify appropriate empiric antimicrobial therapy for outpatient treatment of community
acquired pneumonia in a patient with co-morbid conditions (chronic heart, lung, liver, or
renal disease, or diabetes, etc.)
Identify appropriate empiric antimicrobial therapy for inpatient (non-ICU) treatment of
community acquired pneumonia
Identify appropriate empiric antimicrobial therapy for inpatient ICU treatment of
community acquired pneumonia
Identify the appropriate duration of antibiotic therapy for treatment of community
acquired pneumonia
Identify prevention strategies for community acquired pneumonia
Establish patient outcome parameters and monitor those parameters.
2. DRUG PREPARATION AND DISTRIBUTION: The student will have a working knowledge
of the drug preparation and distribution systems of an institution and be able to (reference 2,
unless otherwise indicated):
Interpret IV admixture requests










Distinguish what is meant by peripheral vs. central administration of parenteral nutrition
Identify and/or list the usual maximum concentration for peripherally administered
dextrose solution in adults and children in order to minimize the incidence of phlebitis
Identify and/or list (at least 2) cases in which parenteral nutrition is frequently used
Identify and/or list (at least 2) cases in which parenteral nutrition is of little or no value
Identify and/or list the determinants of kilocalorie requirements, including factors that
increase energy requirements
Recognize and/or list the purpose of amino acids in parenteral nutrition
Recognize and/or list the kilocalories per gram of lipid, as well as generally available
strengths for lipid emulsions
Given an order for total parenteral nutrition, calculate the volumes of parent solutions,
electrolytes and other additives needed to compound the nutrition formula
Identify factors that increase risk of calcium phosphate precipitation in a parenteral
nutrition solution.
Recognize the Risk Level of Compounded Sterile Products (CSPs) and what measures
are necessary for compounding them within the USP 797 guidelines (Low-Risk level
CSP’s, Medium-Risk level CSP’s and High-Risk level CSP’s). (reference 8).
 Define and/or recognize an immediate-use CSP (reference 8).
Describe the institution's procedure for dispensing and tracking controlled substances.
Demonstrate the ability to accurately perform pharmacy calculations. (e.g., IV admixtures
and continuous infusion drip rates)
10
Identify abbreviations that may be misinterpreted and recognize those that need clarification
to assure proper care (reference 10).
3. PHARMACY MANAGEMENT AND ADMINISTRATION: The student will demonstrate an
understanding of the administrative responsibilities involved in operating a hospital
pharmacy department by:
Identifying the role and activities of pharmacy technicians (reference 11).



Identify and/or list the allowable pharmacist-to-technician ratio in a hospital pharmacy
(by law)
Identify and/or list whether an intern affects the pharmacist-to-technician ratio (by law)
Recognize and/or list duties that may and may not be performed by pharmacy
technicians or support personnel in a hospital pharmacy environment (by law)
4. DRUG POLICY MANAGEMENT: The student will demonstrate familiarity with different drug
management policies in hospital pharmacy by:
Understanding pharmacoeconomic issues associated with institutional pharmacy (reference 4)



Recognize and/or list clinical criteria for parenteral to oral switch therapy in patients with
community acquired pneumonia (CAP)
Recognize and/or list limits for parenteral/oral switch therapy in patients with CAP
Recognize and/or list potential benefits of intravenous to oral sequential antibacterial
therapy (both patient and pharmacoeconomic benefits)
Describing the procedure for reporting and documenting medication errors and adverse drug
reactions and explaining the steps in the institution's ADR reporting/prevention program(s)
Describing
the
procedure
for
handling
"home
medications”
and
drug
samples/pharmaceutical representatives, including policy for medication administration and
prohibited practices related to these areas
Describing the plan or program for attaining Joint Commission Goal #8 of accurately and
completely reconciling medications across the continuum of care (reference 9).
Describing the program or plan for attaining Joint Commission Goal #3 of improving the
safety of using medications (reference 9).
5. PURCHASING AND INVENTORY:
The student will be able to demonstrate an
understanding of purchasing and inventory by:
Describing the procedure for handling of non-formulary or non-stocked drug requests.
11
Medications for the Hospital Pharmacy Examination
(if not listed in Pharmacy Drug Cards, E-facts on-line is the suggested reference)
Darvocet-N
Lortab/Vicoprofen
MS Contin
OxyContin
Percocet
Duragesic
Demerol
Ultram
Ketorolac
Flexeril
Reglan
Zofran
Prochlorperazine
Carafate
Aciphex
Prevacid
Prilosec
Nexium
Protonix
Asacol
Pentasa
Vancomycin
Enoxaparin
Prednisone
Medrol
Flagyl
Amoxil/Trimox
Augmentin
Penicillin V Potassium
Ceftin
Cefzil
Keflex
Omnicef
Biaxin/XL
Erythromycin & Ery-Tab
Zithromax
Sulfamethoxazole/Trimethoprim
Cipro
Levaquin
Avelox
Minocin
Tetracycline
Doxycycline
Famvir
Valtrex
Zovirax
Diflucan
Lamisil
Nizoral
Sporanox
Amphotericin B
Lanoxin
Cordarone
Imdur
Nitrostat
Nitro-Dur
Aldactone
Bumex
Lasix
Demadex
Zaroxolyn
Lamictal
Dilantin
Depakote
Topamax
Lithonate/Lithotabs
Methotrexate
Plaquenil
Imuran
Epoetin Alfa
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VI. Evaluation of the Pharmacy Student
The student should be evaluated by the preceptor twice (midpoint and end of
rotation) during the practicum based on subjective and objective components. The midpoint evaluation should occur by the 17th of a calendar month. See more specific
guidance on evaluation on page 15 of this document.
The evaluation will incorporate the use of the OU/SWOSU Experiential Evaluation form
which will be provided by the College with rotation mailing information or can be
accessed through a secure log-on at http://www.ems-webs.com/Oklahoma/ (contact the
college for technical assistance as needed). The preceptor should fax or mail the
evaluation form back to the College at the end of the rotation (if not completed on-line).
The student needs to receive a copy of the completed, signed evaluation from the
preceptor for insertion into his/her portfolio prior to leaving the rotation.
VII. Grading
The College will issue a grade to the student of Satisfactory or Unsatisfactory based on:
(1) assessment of performance from the preceptor using the OU/SWOSU Experiential
Evaluation, (2) performance on the required exam, (3) and completion of learning
objectives with documentation and signatures via the checklist.
Successful completion of each practicum course requires acceptable completion of all
required tasks. An overall total score of at least 70% will be required for the course with
a grade of 70% also required for each grading component. In addition to inadequate
performance on a grading component, loss of credit (0%) and an Unsatisfactory grade
may occur as a result of (but is not limited to) an unexcused absence, tardiness,
unprofessional conduct, lack of professionalism (including poor work ethic), and/or a
violation of HIPAA.
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Appendix A
Preceptor Responsibilities to the Experiential Education Program
1. Preceptors are expected to maintain contemporary pharmacy practices
sufficient to facilitate experiential education for doctor of pharmacy students at
any level of the professional curriculum. Contemporary pharmacy practice is
evidenced by these activities:
a. active participation with a health care team and provision of therapeutic
recommendations to team members
b. obtaining patient health information (physical findings, laboratory,
medication history, and medical history) commensurate with the type of
pharmacy practice
c. dispensing prescription medications within the facility’s guidelines
d. providing verbal or written medication use information to other health care
providers
e. gathering and organizing patient specific information to identify potential or
on-going drug therapy problems. Specific activities may include but are
not limited to:




obtaining a history (of medications and medical problems) from a
patient
reviewing medical records (to gain admission history, physical findings,
past medical history, medications ordered and received, laboratory and
radiological data)
reviewing pharmacy records (for active orders, medications dispensed
or discontinued)
reviewing other patient records that may provide information needed to
evaluate or solve problems of drug therapy
f. obtaining and interpreting the evidence in the medical literature supporting
the appropriate use of medications to optimize drug therapy outcomes
g. developing therapeutic plans (including prescription and non-prescription
medication selection, dosing, and monitoring plans)
h. providing patients with education about their medication(s) or disease(s) in
an ambulatory setting or prior to discharge from an acute care setting
i. documenting pharmacy work in an appropriate medical record and/or
pharmacy patient profile
j. providing follow-up phone calls or visits with patients or communicating
with involved health care providers to assure that optimal therapeutic
outcomes are attained and maintained
k. providing specialized patient and non-patient care activities that support
unique roles of pharmacists
14
2. All preceptors will have a current, valid, and unrestricted pharmacist and
preceptor license issued by the Oklahoma State Board of Pharmacy.
3. Preceptors will directly supervise and be responsible for all patient care
activities (provision of pharmacy services, drug information, communication of
therapeutic plans to health care providers, and communications with patients)
provided by doctor of pharmacy students. Direct involvement in the patient
care activities outlined in no. 1 above is essential for developing professional
competence and for providing meaningful assessment of student
performance.
4. Evaluations must be conducted for all students assigned and be submitted to
the Office of Experiential Education upon completion.

A mid-point performance evaluation must be documented in writing and
verbally reviewed with each student no later than the 17 th of each month.
If the mid-point evaluation is below expectations, a specific, written plan
for improvement must be developed and signed by the student and
preceptor. The Director of Experiential Education must be notified by the
preceptor and provided a copy of the plan for improvement.

A final performance evaluation must be documented in writing and
verbally reviewed with each student by the final day of the month. The
final evaluation must be submitted on-line by the end of the final rotation
day, but should be printed and signed by both the student and preceptor
and a copy of the signed evaluation must be provided to the student by
the final rotation day of the month.

In all cases where it is possible (that is, those with a computer compatible
with the available assessment software), student evaluations must be
submitted electronically.
15
Appendix B
Preceptor Evaluation Form
(on-line and to be completed by the student)
Preceptor _______________________
Student _________________________
Each of the statements below describes essential characteristics to sustain a learning
experience and facilitate the growth of a professional student through opportunity, interaction,
and assessment. Indicate the rating of your primary preceptor(s) according to the listed scale
for items 1 through 10 and indicate yes or no to items 11 through 13.
4
3
2
1
0
Extremely well done, always performed well
Well done, frequently performed well
Fairly well done, sometimes performed well
Not done, never performed well
Unable to rate on this item
THE PRECEPTOR:
1. Maintained pharmacy practice or learning environment sufficient to facilitate my learning
and my growth as a professional.
2. Sustained responsibilities at the rotation site including provision of care to patients
and/or services to others within a health care system.
3. Assigned specific responsibilities designed to facilitate my learning.
4. Provided consistent and appropriate supervision of my activities and actions.
5. Was able to provide meaningful assessment of my abilities and performance.
6. Displayed enthusiasm for teaching.
7. Provided feedback and asked questions that stimulated my thinking and memory.
8. Increased his/her expectations for my ability to perform to higher levels throughout the
rotation.
9. Provided frequent and appropriate verbal feedback on my performance.
10. Provided a challenging experience that stimulated my growth as a professional.
11. Reviewed my mid-point performance verbally and in writing by the 17th of the month.
Yes
No
12. Performed a final evaluation verbally and in writing at the end of the rotation.
Yes
No
13. Provided a copy of my final evaluation for my portfolio.
Yes
No
Additional comments (necessary for high and low evaluation scores):
16
Appendix C
SITE EVALUATION FORM
(on-line and to be completed by the student)
Student Name:
Date:
Site and city/state:
At the end of the rotation, rank each evaluation item according to the scale 1 – 4, where
1 = needs improvement/disagree, 2 = average/somewhat agree, 3 = very good/agree,
4 = excellent/strongly agree.
Evaluation Items
1. Sufficient orientation to the site was provided.
2. Learning objectives or expectations were established.
3. Activities were consistent with learning objectives or
expectations.
4. Opportunity for active participation was provided.
5. Clarification or explanation was provided when feasible.
6. Constructive feedback was provided.
7. Positive feedback was provided.
8. The environment promoted learning.
9. Information resources were adequate for learning.
10. My expectations for learning were met or exceeded.
Rank
(circle one)
1 2 3 4
1 2 3 4
1 2 3 4
1
1
1
1
1
1
1
2
2
2
2
2
2
2
3
3
3
3
3
3
3
4
4
4
4
4
4
4
What are the positive aspects of this site?
In what ways might the site improve the learning experience for students?
Other comments (consider expanding on particularly low or high ranking evaluation items):
Return to: University of Oklahoma College of Pharmacy, P.O. Box 26901, CPB 135B,
Attn: Director of Experiential Programs, Oklahoma City, OK 73126-0901 (fax: 405/271-3531)
17
Appendix D
Hospital Pharmacy Practicum
Practice site: _________________________
Student: _______________________
This check sheet is to be utilized by the student in concert with his/her preceptor(s) as a method to
track the completion of key learning objectives for the rotation. At the completion of the rotation, this
check sheet must be signed by both the preceptor and student and placed in section IV of the student
rotation portfolio.
I. PATIENT CARE
Yes
No
N/A
Demonstrates ability to effectively communicate by performing medication histories.
Yes
No
N/A
Utilizes a medication record to perform an appropriate drug utilization review.
Yes
No
N/A
Communicates drug information and pertinent patient information to other health
care professionals.
Yes
No
N/A
Provides appropriate information and advice to patients, using appropriate
counseling techniques and utilizing terminology appropriate to the patient’s
level of understanding.
Yes
No
N/A
Demonstrates the application of pharmacokinetic principles to patient care.
Yes
No
N/A
Establishes patient outcome parameters and monitors those parameters.
II. DRUG PREPARATION AND DISTRIBUTION
Yes
No
N/A
Interprets medication and IV admixture requests and is able to determine accuracy,
completeness, and legality, and prepare an appropriate label for the medication in
accordance with guidelines.
Yes
No
N/A
Describes controlled substance laws and institutions procedure for dispensing controlled
substances.
Yes
No
N/A
Reviews orders for appropriateness against patient profile, making additions and
deletions along with an understanding of steps needed to clarify a questionable order.
Yes
No
N/A
Accurately fills unit dose and bulk medication orders including proper selection of
container.
Yes
No
N/A
Demonstrates proper aseptic technique, and ability to prepare admixture solutions.
Yes
No
N/A
Identifies common IV incompatibilities along with pertinent information on administration,
and stability of parenteral medications.
Yes
No
N/A
Demonstrates ability to accurately perform pharmacy calculations (i.e., IV admixtures,
drip rates, and extemporaneously compounded preparations).
Yes
No
N/A
Describes the hospital’s procedure for dealing with outpatient prescriptions.
Yes
No
N/A
Demonstrates use and knowledge of auxiliary labeling.
Yes
No
N/A
Demonstrates competency in the compounding and/or repackaging of a pharmaceutical
product.
Yes
No
N/A
Demonstrates knowledge about satellite pharmacy services, drug information, and
clinical services performed in practice.
18
III. PHARMACY MANAGEMENT AND ADMINISTRATION
Yes
No
N/A
Understands pharmacy-related hospital committee meetings, especially Pharmacy
and Therapeutics and Quality Assurance committees.
Yes
No
N/A
Describes the lines of communication and shared services between other departments.
Yes
No
N/A
Explains some Policies and Procedures and discusses pertinent guidelines of the Joint
Commission on Accreditation of Healthcare Organizations (JCAHO).
Yes
No
N/A
Identifies the role and activities of pharmacy technicians.
Yes
No
N/A
Identifies the organizational structure of the pharmacy department.
IV. DRUG POLICY MANAGEMENT
Yes
No
N/A
Discusses the Drug Use Evaluation process.
Yes
No
N/A
Discusses the procedure for reporting and documenting medication errors and
adverse drug reactions and tracing the steps in the ADR reporting program.
Yes
No
N/A
Describes the institution’s policies and procedures for handling investigational drugs.
Yes
No
N/A
Identifies the procedure for handling “meds from home” and drug samples.
Yes
No
N/A
Describes pertinent aspects of the institutional formulary system/procedures.
Yes
No
N/A
Discusses current and/or anticipated pharmacoeconomic issues.
Yes
No
N/A
Describes issues on how therapeutic and generic equivalence affects the formulary.
V. PURCHASING AND INVENTORY
Yes
No
N/A
Traces inventory control activities, including ordering, checking, stocking, and
physical inventory control.
Yes
No
N/A
Identifies and performs required procedures for ordering, inventory, and
prescription filing of controlled substances.
Yes
No
N/A
Describes the procedure for handling manufacturer recalls of medications.
Yes
No
N/A
Describes the procedure for handling non-formulary or non-stocked drug orders.
Signatures below indicate that the documentation above is an accurate reflection of activities and content of the
rotation. Level of competency and assessment can be further documented on the OU/SWOSU Experiential
Evaluation.
Student signature
Date:
Preceptor signature
Date:
Preceptor comments:
19
APPENDIX E
OU/SWOSU Experiential Evaluation
PRECEPTOR INSTRUCTIONS
General Instructions:
 Review the evaluation form and decide which components will be covered on your rotation.
 If an area will not be covered during the rotation, mark “n/a” for not applicable.
 Share this information with students on the 1st day of the rotation.
 Note that certain items do not have “n/a” as an option, as students are expected to demonstrate knowledge, skills, or attitudes in these categories on every
rotation.
 An individual rotation site is not expected to cover all the evaluation areas, only those pertinent to the practice setting and rotation.
 Space is provided at the end for you to add and evaluate unique competencies at your site.
 If you have any concerns about the student’s professional behavior or interpersonal skills, please contact the experiential office.
Using the 1 to 5 Scale:
 When performing midpoint and final evaluation, consider a 3 rating as “meets expectations” and begin assessing each item at the 3 column.

If the student is performing lower than the criteria for a score of 3, read the criteria for 2, and if these criteria aren’t met, read the criteria for 1.

If the student is performing above the criteria for a score of 3, read the criteria for 4, and if these criteria do not fit the performance, review the criteria for 5.

For each competency that you evaluate, mark one rating of 1, 2, 3, 4, or 5 which best describes the student’s performance.
Midpoint and Final Evaluation Instructions:
 Rate the student’s performance according to the 1 to 5 scale. If an evaluation category was not covered, mark “n/a.”
Approximately 2 weeks into the rotation, perform a midpoint evaluation.
 At the midpoint evaluation, review the evaluation form with the student and provide feedback to the student about your expectations for further progress
during the remaining 2 weeks of the rotation
 Review the final evaluation form with the student.
 Both the preceptor and student should sign and date both the midpoint and final evaluation at the end of the evaluation form. Please provide a copy to
the student to place in his or her portfolio.
Written comments:
 Are required for any score of 1 (“unacceptable performance”) OR 5 (“exceeds expectations”).
 Are encouraged for all areas evaluated
If you are unable submit the evaluation on-line, make a copy of the completed evaluation for your files and send the original to your local campus:
OU College of Pharmacy
OU Schusterman Center/College of Pharmacy
P.O. Box 26901, CPB 135B
4502 East 41st Street, 1H15
Oklahoma City, OK 73126-0901
Tulsa, OK 74135
Vincent Dennis, Pharm.D.
Director of Experiential Education
Phone 405-271-6878, ext. 47372
Fax 405-271-3531
Email: [email protected]
Nancy Ray, Pharm.D.
Assistant Director of Experiential Education (Tulsa)
Phone 918-660-3587
Fax 918-660-3580
Email: [email protected]
20
OU/SWOSU Experiential Evaluation Form
Student:
Rotation Site:
Preceptor:
Date (Month & Year):
Knowledge Base
Drug &
disease state
knowledge
Midpt
Final
□ 1
 Guesses at basic
disease & drug
information. Major
gaps in essential
knowledge.
 Unable to relate to
patient care
□ 2
 Often unable to explain
basic principles of drugs
& diseases
 Has difficulty relating to
patient care
□ 1
 Unable to obtain
obvious patient
information. Unable
to identify patient’s
primary reason for
seeking care
 Selects inappropriate
resources for
information or unable
to elicit information
from appropriate
resources
□ 2
 Requires assistance in
obtaining obvious patient
information. Requires
prompting to identify
patient’s primary reason
for seeking care
 Inconsistently uses
appropriate resources
for information (e.g.
patient, caregiver,
medical record, other
healthcare
professionals)
□ 3
 Explains basic principles
of drugs & diseases but
lacks detail
 Usually able to relate to
patient care, but requires
prompting
□ 4
 Explains drugs & diseases
often in detail
 Usually relates to patient
care with little to no
prompting
□ 5
 Explains drugs & diseases in
detail & depth
 Always relates to patient care without
prompting
Comments
Provision of Pharmaceutical Care
Information
gathering &
identifying
patient needs
Midpt
Final
□ 3
 Obtains obvious patient
information. Able to
identify patient’s primary
reason for seeking care.
 Uses some appropriate
resources for information
(e.g. patient, caregiver,
medical record, other
healthcare professionals)
□ 4
 Efficiently obtains
complete patient
information & makes
attempt to elicit details.
Able to identify patient’s
primary reason for seeking
care
 Uses appropriate
resources for information
(e.g. patient, caregiver,
medical record, other
healthcare professionals)
□5
 Efficiently obtains complete
& detailed patient
information. Able to identify
patient’s primary reason for
seeking care
 Efficiently uses appropriate
resources for information
(e.g. patient, caregiver,
medical record, other
healthcare professionals)
□
n/a
21
Assessment &
interpretation
of information
Midpt
Final
Therapeutic
plan
development
Midpt
Final
Therapeutic
plan
monitoring
Midpt
Final
□ 1
 Unable to interpret
subjective & objective
patient data
 Unable to identify
drug-related problems
 Unable to develop a
patient-specific
problem list
□ 2
 Interprets some
subjective & objective
patient data
 Identifies some basic
drug-related problems
 Develops patient-specific
problem list, unable to
prioritize
□ 3
 Interprets most subjective
& objective patient data
 Identifies basic drugrelated problems
 Develops patient-specific
problem list and usually
able to prioritize problems,
but sometimes needs
prompting
□ 4
 Interprets all pertinent
patient data & usually
makes reasonable
assumptions when data is
incomplete
 Identifies majority of drugrelated problems
 Develops patient-specific
problem list and usually
able to prioritize
□5
 Interprets all pertinent patient
data & makes reasonable
assumptions when data is
incomplete
 Identifies all drug-related
problems
 Develops patient-specific
problem list with prioritization
□
n/a
□ 1
 Unable to recommend
appropriate, patientspecific drug therapy
regimens & selfmanagement
techniques
 Unable to prevent &
resolve medicationrelated problems
□ 2
 Sometimes recommends
reasonable drug therapy
regimens, lacks rationale
& individualization
 Able to prevent & resolve
basic medication-related
problems with guidance
□ 3
 Recommends reasonable
drug therapy regimens,
although choice is not
always optimal
 Able to prevent & resolve
basic medication-related
problems
□ 2
 Able to identify some
therapeutic endpoints
Unable to select proper
monitoring parameters
□ 3
 Usually able to identify
therapeutic endpoints &
monitoring parameters
□5
 Recommends optimal patientspecific drug therapy
regimens & self-management
techniques with rationale &
supporting literature
 Develops alternate plan
based on patient’s changing
needs
 Able to prevent & resolve
medication-related problems
independently
□5
 Consistently identifies
therapeutic endpoints;
consistently identifies &
understands implications of
monitoring parameters
□
n/a
□ 1
 Unable to identify
therapeutic endpoints
& monitoring
parameters
□ 4
 Usually recommends
optimal patient-specific
drug therapy regimens &
self-management
techniques with rationale
 Sometimes develops
alternate plan based on
patient’s changing needs
 Able to prevent & resolve
medication-related
problems
□ 4
 Consistently identifies
therapeutic endpoints &
monitoring parameters
□
n/a
Comments
22
Practice Management
Pharmacy
Operations



Midpt
Final

□1
Fails to comprehend
basic concepts of
inventory control,
financial decisionmaking, the
importance of being
sensitive to personnel
management issues,
and the role of
marketing in
pharmacy practice
Possesses no
knowledge of
dispensing system
Unable to utilize
onsite technology
Is unable to apply
pharmacy laws and
regulations to practice




□ 2
Comprehends some
concepts including
inventory control,
financial decisionmaking, the importance
of being sensitive to
personnel management
issues, responsibilities of
health professionals, and
the role of marketing in
pharmacy practice.
Possesses little
knowledge of dispensing
system
Requires repeated
prompting to utilize onsite
technology
Requires assistance in
applying pharmacy law
and regulations in
practice
□ 3
 Understands most of the
concepts including
inventory control, financial
decision-making, the
importance of being
sensitive to personnel
management issues,
responsibilities of health
professionals and the role
of marketing in pharmacy
practice.
 Possesses basic
knowledge and
understanding of the
dispensing system
 Requires occasional
prompting to utilize onsite
technology
 Requires occasional
assistance in applying
pharmacy law and
regulations to practice
□ 4
 Understands concepts
including inventory control,
financial decision-making,
the importance of being
sensitive to personnel
management issues,
responsibilities of health
professionals, and the role
of marketing in pharmacy
practice.
 Possesses knowledge and
understanding of the
dispensing system
 Utilizes onsite technology
with minimal assistance
 Needs minimal assistance
with applying pharmacy
laws and regulations to
practice
□ 5
 Understands concepts and
displays a detailed
understanding about
inventory control, financial
decision-making, the
importance of being sensitive
to personnel management
issues, responsibilities of
health professionals, and the
role of marketing in pharmacy
practice.
 Possesses knowledge and
understanding of the
dispensing system and is able
to troubleshoot problems
 Able to fully utilize onsite
technology
 Applies pharmacy law and
regulations to practice
□
n/a
Comments
23
Medication Use Systems
Medication
Use
Evaluation
Midpt
Final
□ 1
 Unaware of the
pharmacy or
institution’s formulary
policy
 Does not participate
in the pharmacy or
institution’s reporting
of medication errors,
ADR’s and DUE’s.
 Unaware of and
unable to apply
principles of
outcomes research,
pharmacoeconomics,
and quality
assessment to
provision or
evaluation of patient
care
□ 2
 Understands some of the
pharmacy or institution’s
formulary policy
 Sometimes participates
in the pharmacy or
institution’s reporting of
medication errors, ADR’s
and DUE’s
 Aware of but unable to
apply principles of
outcomes research,
pharmacoeconomics,
and quality assessment
to provision or evaluation
of patient care
.
□ 3
 Understands most of the
pharmacy or institution’s
formulary policy
 Participates in the
pharmacy or institution’s
reporting of medication
errors, ADR’s and DUE’s.
 Aware of and sometimes
applies principles of
outcomes research,
pharmacoeconomics, and
quality assessment to
provision or evaluation of
patient care



□ 4
Comprehends the
pharmacy or institution’s
formulary policy
Independently
participates in the
pharmacy or institution’s
reporting of medication
errors, ADR’s and DUE’s
Usually applies
principles of outcomes
research,
pharmacoeconomics,
and quality assessment
to provision or evaluation
of patient care



□5
Comprehends and utilizes
the pharmacy or
institution’s formulary policy
Independently participates
in the pharmacy or
institution’s reporting of
medication errors, ADR’s
and DUE’s and can
interpret data
Consistently applies
principles of outcomes
research,
pharmacoeconomics, and
quality assessment to
provision or evaluation of
patient care
□
n/a
Comments
24
Pharmaceutical Dispensing
Dispensing
and
Compounding



Midpt
Final

□ 1
Makes errors in
dispensing
prescriptions.
Fails to obtain
necessary information
to evaluate
prescriptions
Unable to accurately
calculate and
measure quantities of
ingredients
Lacks sufficient skills
to compound
prescriptions




□ 2
Makes occasional errors
in dispensing
prescriptions.
Misses important
information necessary to
evaluate prescriptions
Makes mistakes in
calculating and
measuring quantities of
ingredients
Has difficulty
compounding
prescriptions
□ 3
 Accurately and safely
dispenses prescriptions.
 Obtains some relevant
information necessary to
evaluate prescriptions
 Can accurately calculate
and measure quantities of
ingredients
 Has sufficient skills to
compound prescriptions
but requires continuous
pharmacist guidance




□ 4
Accurately and safely
dispenses prescriptions.
Identifies relevant
information to evaluate
prescriptions
Can accurately calculate
and measure quantities
of ingredients and
identifies incompatibilities
Prepares compounded
prescriptions accurately
with some pharmacist
guidance
□5
Accurately, safely, and
efficiently dispenses
prescriptions.
Obtains all relevant
information to evaluate
prescriptions
Can accurately calculate
and measure quantities of
ingredients, identifies
incompatibilities and
resolves incompatibilities
Prepares compounded
prescriptions accurately
and independently.
Prepares an aesthetically
appropriate product
□
n/a
□ 5
 Consistently identifies
opportunities for patient
health promotion tailoring to
specific patient needs
 Counsels patients regarding
wellness and health
behaviors specific to
individual needs
 Information provided is
accurate, appropriate, and
complete
□
n/a




Comments
Public Health
Health
Promotion/
Disease
Prevention
Midpt
Final
□1
 Shallow knowledge of
areas for patient
health promotion
 Fails to identify
opportunities and
makes no attempt to
promote wellness and
health behaviors
when talking with
patients
 Information provided
is constantly
inaccurate,
inappropriate, or
incomplete
□ 2
 Occasionally identifies
opportunities for patient
health promotion
 Makes little attempt to
counsel patients
regarding wellness and
health behaviors
 Information provided is
sometimes inaccurate,
inappropriate, or
incomplete
□ 3
 Usually identifies
opportunities for patient
health promotion
 Usually attempts to
counsel patients regarding
wellness and health
behaviors
 Information provided is
accurate and appropriate
but may be incomplete
□ 4
 Consistently identifies
opportunities for patient
health promotion
 Counsels patients
regarding wellness and
health behaviors
 Information provided is
accurate, appropriate, and
generally complete
Comments
25
Professional Communication
Patient
Counseling and
Drug
Information
Skills



Midpt
Final

Communication
Skills



Midpt
Final

□1
Unable to counsel
patient and/or
provides incorrect
information
Unable to accurately
identify the
requestor’s need
Does not select
source of information
appropriate for
situation or does not
interpret literature or
information correctly;
does not seek
guidance
Response formulated
is incomplete or
unacceptable
□1
Written work is poorly
organized and
incomplete
Does not listen
Does not make eye
contact, unable to
answer questions
Displays
inappropriate
nonverbal
communication
□ 2
Counsels patient but
requires significant
interventions from
preceptor
Has poor understanding
of requestor’s need
Retrieval of information
is not thorough and
review of information is
incomplete, needs much
guidance
Response formulated
must be redone for
acceptability
□ 3
 Effectively counsels
patient with minimal
interventions from
preceptor
 Has fair understanding of
requestor’s need
 Appropriately researches
most literature needed,
needs some guidance
 Response formulated
needs revision for
acceptability
□ 4
 Effectively counsels patient
without interventions from
preceptor
 Asks appropriate questions
to requestor to determine
requestor’s information
need
 Identifies source of
information suitable for
situation and appropriately
researches all the literature
needed with little guidance
 Delivers well organized
response with minor
revisions
□ 5
 Effectively counsels patient without
interventions. Counseling is well
organized and patient specific
 Understands requestor’s need,
elicits new information from the
requestor, and confirms information
with requestor
 Timely identification of information
and appropriate retrieval and
interpretation of information with no
guidance
 Effectively delivers information in a
well organized response and
method appropriate for situation with
no revisions necessary
□ 2
 Incomplete or excessive
information presented.
Written work has spelling
or grammatical errors;
rewrite required
 Listens but is easily
distracted or is
inattentive
 Speaks unclearly, is
disorganized, mumbles
or uses incorrect
terminology; is
apprehensive, lacks
assertiveness
 Occasionally displays
inappropriate nonverbal
communication
□ 3
 Information is generally
complete. Student needs
assistance with data
organization or
appropriate wording.
Occasional rewrites
needed
 Listens but is sometimes
distracted
 Is clear and organized
with speech but does not
probe for questions or
misunderstandings
 Displays appropriate
nonverbal communication
□ 4
 Information is complete,
concise and well organized.
Uses appropriate medical
terminology. No
grammatical or spelling
errors.
 Listens attentively
 Is clear and organized with
speech. Probes for
questions and
misunderstandings
 Displays appropriate
nonverbal communication
□ 5
 Exceptional ability to organize
information into concise format. Is
flexible in adapting writing style to
different formats. Excellent medical
terminology and grammar that meet
standards for publication quality
 Actively listens and clarifies
information
 Is clear and organized with speech
and is assertive. Probes for
questions and misunderstandings.
 Becomes an essential team
member.
 Displays appropriate nonverbal
communication




Comments
26
Professionalism and Accountability
Professional
Behavior
Midpt
□ 2
 Initiates activity only on
request, follows through
on questions only when
pressured, attempts to
set priorities, avoids
accepting responsibility.
Does not complete
assignments on time
 Inconsistently
demonstrates sensitivity
for patient confidentiality
 Occasional regard for
patient’s well-being.
Occasionally arrives late
or leaves early
 Reluctantly accepts
feedback, but does not
change behavior
□ 3
 Meets requirement of the
experience and
occasionally volunteers
for additional duties.
Assignments are
completed on time. Shows
proper motivation in work
and accepts responsibility
when asked.
 Usually shows regard for
the well-being of patient,
maintains patient
confidentiality
 Arrives on time and does
not leave until basic
responsibilities are met
 Responds to feedback
and usually alters
behavior
□ 4
 Asks questions freely, finds
answers on his/her own,
assignments are promptly
completed. Effective time
management and priority
setting. Seeks
responsibility for various
facets of patient care.
 Always shows regard for
the well-being of the patient
as a priority. Maintains
patient confidentiality
 Arrives on time and willing
to volunteer additional time
for projects and patient
care activities
 Solicits feedback on
performance and usually
modifies behavior to
improve performance
□ 5
 Uses down time soliciting questions,
researches related areas.
Assignments thoroughly completed.
Excellent time management skills
and priority setting. Always
demonstrates initiative in seeking
responsibility for various facets of
patient care.
 Always shows regard for the
patient’s well-being and makes it a
priority.
 Arrives on time. Often arrives early
& stays late. Develops studentinitiated projects.
 Solicits feedback and consistently
modifies behavior to improve
performance.
□1
 Does not understand
the pharmacist’s code
of ethics and
therefore is unable to
utilize it consistently
 Does not recognize
and/or respect
patients’
socioeconomic,
religious, cultural, and
moral concerns
and/or value systems
 Does not display
empathy when
appropriate for the
situation
□ 2
 Occasionally acts in
accordance with the
pharmacist’s code of
ethics
 Inconsistently recognizes
and/or respect patients’
socioeconomic, religious,
cultural, and moral
concerns and/or value
systems
 Occasionally displays
empathy when
appropriate for the
situation
□ 3
 Generally uses the
pharmacist’s code of
ethics in professional
interactions
 Often recognizes and
respects patients’
socioeconomic, religious,
cultural, and moral
concerns and/or value
systems
 Displays empathy
appropriate to the
situation
□ 4
 Utilizes the pharmacist’s
code of ethics consistently
in all professional
interactions
 Consistently recognizes
and respects patients’
socioeconomic, religious,
cultural, and moral
concerns and/or value
systems
 Displays empathy
appropriate to the situation
□ 5
 Utilizes and has an in depth
understanding of the pharmacist’s
code of ethics
 Consistently recognizes, respects,
and makes accommodations for
patients’ socioeconomic, religious,
cultural, and moral concerns and/or
value systems
 Displays empathy appropriate to the
situation
Final
Social and
Ethical
Awareness
Midpt
□1
 Unable to set
priorities or manage
time. Does not
complete assignment,
Lacks motivation
 No regard for
patient’s well-being.
Breaches
confidentiality.
 Arrives late or leaves
early. At least one
unexcused absence
 Ignores or resents
feedback and does
not change
professional behavior
Final
Comments
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Additional Competencies (write in your own rotation-specific competencies below if desired)
Competency 1:
Midpt
□1
□ 2
□ 3
□ 4
□ 5
□1
□ 2
□ 3
□ 4
□ 5
Final
Comments
Competency 2:
Midpt
Final
Comments
______ hours of time unrelated to College events were missed and not made up by conclusion of the rotation month.
Midpoint Evaluation Date:
Preceptor signature:
Student signature:
Final Evaluation Date:
Preceptor signature:
Student signature:
This evaluation form was adapted from the University of Cincinnati College of Pharmacy.
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