University of Arkansas for Medical Sciences – Diagnostic Medical Sonography Program

Clinical Instructor’s Evaluation of the Student 2005©

Student’s name	Rotation Number: Rotation Dates
Clinical Site	Clinical Instructor(s)

The student will not be expected to perform a complete sonographic examination until they have received appropriate instruction for that examination. N/A is Not Applicable or Not Observed and is not used in grade calculations.
Evaluate each area of performance (Poor = 1, Good = 5, Excellent = 10). For scores of less than 7, the instructor should identify the item by number and give a brief explanation to help the student improve on that item. ©2005 All rights reserved.

	Affective Domain	1	2	3	4	5	6	7	8	9	10	N/A
1	Student identifies patient and interacts appropriately.
2	Student communicates effectively with the clinical staff.
3	Student cooperates with the clinical staff.
4	Student’s actions in patient care are appropriate.
5	Student is prompt and professional in actions and in appearance.
6	Student is attentive when patient examinations are in progress.
7	Student completes assigned tasks in a timely fashion.
8	Student exercises professional conduct in the clinical setting.
	Psychomotor Domain
9	Student turns on equipment and performs laboratory start up.
10	Student prepares the examination room.
11	Student performs appropriately in the clinical setting.
12	Student aligns the plane of view on longitudinal and transverse structures.
13	Student uses transducer appropriately to display anatomy.
14	Student cleans transducer after use.
15	Student turns off equipment and performs laboratory shut down.
	Cognitive Domain
16	Student Identifies the pertinent clinical questions and the goal of the examination.
17	Student recognizes significant clinical information and historical facts from the patient and the medical records, which may impact the diagnostic examination; and the student keeps medical records according to the clinic’s protocol.
18	Student can relate sonograms to other modalities and recognizes normal anatomy.
19	Student reviews data from current and previous examinations to produce a written/oral summary of technical findings, including relevant interval changes, for the interpreting physician’s reference.