ROTATION: MONTH/YEAR OF ROTATION:
LOCATION:
RESIDENT:
Please check the applicable response in
each area:
HONORS
= EXCEEDS EXPECTED COMPETENCIES FOR LEVEL OF
TRAINING
PASS = MEETS
EXPECTED COMPETENCIES FOR LEVEL OF TRAINING
FAIL = FAILS TO MEET EXPECTED COMPETENCIES FOR
LEVEL OF TRAINING
NO/NA =
NOT OBSERVED OR NOT APPLICABLE, CANNOT EVALUATE
MEDICAL KNOWLEDGE
1. FUND OF KNOWLEDGE SPECIFIC TO CONTENT AREA (evidenced by reading about patients, demonstrates knowledge in patient care, comprehension of pathophysiology and development of differential diagnoses).
|
Honors (Comments requested) |
Pass |
Fail(Comments required) |
NO/NA |
___________________________________________________________________________________________
___________________________________________________________________________________________
2. DIAGNOSTIC/THERAPEUTIC TECHNOLOGIES: (demonstrates good psychomotor skills, orders or performs appropriate diagnostic studies, has adequate interpretative skills, provides effective therapeutics)
|
Honors (Comments requested) |
Pass |
Fail(Comments required) |
NO/NA |
___________________________________________________________________________________________
___________________________________________________________________________________________
PATIENT CARE
3. ASSESSMENT: (accurate and complete collection of data as evidenced by history and physical, patient presentation, charting, refining of differential diagnosis)
|
Honors (Comments requested) |
Pass |
Fail(Comments required) |
NO/NA |
___________________________________________________________________________________________
___________________________________________________________________________________________
4. MANAGEMENT: (demonstrates problem solving skills, sound clinical judgment, attentiveness to patient care issues. Carries out treatment plan, writes quality progress notes, requests appropriate consultations).
|
Honors (Comments requested) |
Pass |
Fail(Comments required) |
NO/NA |
___________________________________________________________________________________________
___________________________________________________________________________________________
PRACTICE-BASED LEARNING AND IMPROVEMENT
5. MOTIVATION: (Evidence of reading, does study assignments, shows interest, seeks learning opportunities).
|
Honors (Comments requested) |
Pass |
Fail(Comments required) |
NO/NA |
___________________________________________________________________________________________
___________________________________________________________________________________________
Please turn over to complete other side
PROFESSIONALISM
6. ATTENDANCE/DEPENDABILITY: (is prompt, attends rounds, clinics, & conferences, writes daily chart notes and does other expected work)
|
Honors (Comments requested) |
Pass |
Fail(Comments required) |
NO/NA |
___________________________________________________________________________________________
___________________________________________________________________________________________
7. BEHAVIOR: (is a good team player, has courteous and effective communication skills, demonstrates integrity in dealings with others, has an even temperament and friendly demeanor)
|
Honors (Comments requested) |
Pass |
Fail(Comments required) |
NO/NA |
___________________________________________________________________________________________
___________________________________________________________________________________________
INTERPERSONAL
AND COMMUNICATION SKILLS
8. PHYSICIAN/PATIENT RAPPORT: (demonstrates compassion, appropriate concern, and good communication skills. Respects the rights and dignity of the patient, demonstrates ethical behavior)
|
Honors (Comments requested) |
Pass |
Fail(Comments required) |
NO/NA |
___________________________________________________________________________________________
___________________________________________________________________________________________
SYSTEM-BASED
PRACTICE
9. UNDERSTANDING OF HEALTHCARE SYSTEM: (effectively uses appropriate resources (e.g., home health, discharge planning, PT/OT, etc.), efficiently uses protocols, advocates for patient’s needs)
|
Honors (Comments requested) |
Pass |
Fail(Comments required) |
NO/NA |
___________________________________________________________________________________________
___________________________________________________________________________________________
Other Comments:
|
Resident
complied with all ACGME duty hour requirements |
|
yes |
|
no |
|
Don’t
know |
||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
I
directly observed the resident on more than one day during this rotation |
|
yes |
|
no |
|
|||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
I
directly observed the resident provide care for more than one patient. |
|
yes |
|
no |
|
|||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
____________________________________
__________________________________________ ______________________________
NAME
(Print) SIGNATURE TITLE
(Print)
Revised 09/15/06
RETURN TO: Stacey Riddling,
Family Practice Residency Coordinator, Slot 530