Download Area of Evaluation - Communication Area of Evaluation – Problem

1
Fourth Year Preceptor Evaluations
Printed Student Name___________________________ Start Date___________ End Date___________
Printed Preceptor Name and Degree______________________________ Discipline________________
Area of Evaluation - Communication
Question
Rating
1.) Effectively listen to patients,
family, peers, & healthcare team
Always
Often
Adequately
Rarely
Never
N/A
2.) Demonstrates compassion and
respect in patient communications
Always
Often
Adequately
Rarely
Never
N/A
3.) Effectively collects chief complaint
and history
Always
Often
Adequately
Rarely
Never
N/A
4.) Considers whole patient: social,
spiritual & cultural concerns
Always
Often
Adequately
Rarely
Never
N/A
5.) Efficiently prioritizes essential
from non-essential information
Always
Often
Adequately
Rarely
Never
N/A
6.) Assures patient understands
instructions, consents & medications
Always
Often
Adequately
Rarely
Never
N/A
7.) Presents cases in an accurate,
concise, well organized manner
Always
Often
Adequately
Rarely
Never
N/A
Area of Evaluation – Problem Solving
8.) Identifies important questions and
separates data in organized fashion
organizing positives & negatives
Always
Often
Adequately
Rarely
Never
N/A
9.) Discerns major from minor patient
problems
Always
Often
Adequately
Rarely
Never
N/A
10.) Formulates differential
identifying most common diagnoses
Always
Often
Adequately
Rarely
Never
N/A
Always
Often
Adequately
Rarely
Never
N/A
Always
Often
Adequately
Rarely
Never
N/A
11.) Identifies indications for &
applies findings from the most
common radiographic and diagnostic
tests
12.) Identifies correct management
plan considering contraindications &
interactions
2
Fourth Year Preceptor Evaluations
Printed Student Name___________________________ Start Date___________ End Date___________
Area of Evaluation – Clinical Skills
13.) Assesses vital signs & triages
patient according to degree of illness
Always
Often
Adequately
Rarely
Never
N/A
14.) Performs good auscultory,
palpatory & visual skills
Always
Often
Adequately
Rarely
Never
N/A
15.) Performs a thorough physical
exam pertinent to this rotation
Always
Often
Adequately
Rarely
Never
N/A
Rarely
Never
N/A
Area of Evaluation - OMM
16.) Applies osteopathic
manipulative medicine successfully
when appropriate
Always
Often
Adequately
Area of Evaluation – Medical Knowledge
17.) Can identify & correlate
anatomy, pathology and
pathophysiology related to most
disease processes
Always
Often
Adequately
Rarely
Never
N/A
Always
Often
Adequately
Rarely
Never
N/A
Always
Often
Adequately
Rarely
Never
N/A
20.) Actively seeks feedback from
preceptor on areas for improvement
Always
Often
Adequately
Rarely
Never
N/A
21.) Correlates symptoms & signs
with most common diseases
Always
Often
Adequately
Rarely
Never
N/A
18.) Self-motivated learner
demonstrating interest and
enthusiasm about patient cases,
researches literature
19.) Thorough & knowledgeable in
researching evidence based
literature
3
Fourth Year Preceptor Evaluations
Printed Student Name___________________________ Start Date___________ End Date___________
Area of Evaluation – Professional & Ethical
22.) Is dutiful, arrives on time & stays
until all tasks are complete
Always
Often
Adequately
Rarely
Never
N/A
23.) Consistently follows through on
patient care responsibilities
Always
Often
Adequately
Rarely
Never
N/A
24.) Accepts & readily responds to
feedback, is not resistant to advice
Always
Often
Adequately
Rarely
Never
N/A
Always
Often
Adequately
Rarely
Never
N/A
26.) Displays integrity & honesty in
medical ability and documentation
Always
Often
Adequately
Rarely
Never
N/A
27.) Acknowledges errors, seeks to
correct errors appropriately
Always
Often
Adequately
Rarely
Never
N/A
28.) Is well prepared for and seeks to
provide high quality patient care
Always
Often
Adequately
Rarely
Never
N/A
Always
Often
Adequately
Rarely
Never
N/A
25.) Assures professionalism in
relationships with patients, staff, &
peers
29.) Identifies the importance to care
for underserved populations in a
non-judgmental & altruistic manner
Clinical Skills Witnessed where student demonstrated satisfactory performance (check all that apply )
Performing Vital
Signs
Pap Smear
Venipuncture
ABG
Foley Catheterization
Urinalysis
CPR
Suturing
Intubation
Peripheral IV
Airway Management
Prenatal Exam
Joint Injections
Ultrasound
interpretation with
assistance
Splint/Casting
Interpretation of maternal and
fetal monitor strips with over-read
Basic ACLS Principles
Injection
N/A
Please identify the areas where the student has shown the greatest strengths:
4
Fourth Year Preceptor Evaluations
Please identify the areas where the student needs the most improvement:
Physician Information Section:
The following information must be completed in full in order for the student to receive credit for his/her rotation. The
information is also required for the physician to receive Continuing Medical Education credit for precepting.
Please Print:
First Name: _________________________________________
Middle Name: _______________________________________
Last Name: _________________________________________
Name of Practice or Hospital: _______________________________________________________________
Region: _____________________________
Mailing Address: _________________________________________________________________________
City: _________________________ State: ______________________ Zip Code: _____________________
Please indicate:
D.O.
M.D.
AOA number if D.O.: _______________________________
Preceptor Signature: _______________________________ Date: _______________________________
Student Section:
I understand that the Physician Information section above must be completed in full for my rotation evaluation to be
accepted by the Edward Via Virginia College of Osteopathic Medicine clinical department and for me to be given credit for
my rotation.
Student Signature: ___________________________________________
Printed Student Name: ________________________________________
Date: ___________________________________