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* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
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: ___________________________________