PA and 4th Year MD Student Evaluation » Mobile Outreach Clinic » College of Medicine

Contributing Evaluation Form

Instructions: -Please select one descriptive box for each of the 14 competencies listed below -Most students should be graded Acceptable (~70% of students) -Advanced should be chosen for role model students (special skills should be present to achieve this category) -Students with a critical deficiency or multiple deficiencies should be given opportunity to improve after mid-month feedback.

Evaluator Name*
Other Evaluator Name
Date*
MM slash DD slash YYYY
Student Name*
First Last
Rotation*
- Mobile Outreach Clinic
Site Day*
- Monday
- Tuesday
- Wednesday
- Thursday
- Friday
Patient care

	Critical Deficiencies -- Unable to collect accurate history or physical exam	Improvement Needed -- Inconsistently able to acquire accurate history	Proficient: Meets Expectations for Levels of Training -- Consistently acquires accurate and relevant histories	Ahead of Expectations for Level of Training -- Acquires H&P in a prioritized, & hypothesis-driven fashion	Exceptional: Special Skill Demonstrated -- Obtains historical subtleties, that improve the differential diagnosis	Not Observed
a. Medical Interview & Physical Exam: Student synthesizes essential, accurate information to define patient's clinical problem(s). [PC1, EPA 1,10]

	Critical Deficiencies -- Care plans are often incomplete or inaccurate	Improvement Needed -- Inconsistently develops an appropriate care plan	Proficient: Meets Expectations for Levels of Training -- Consistently develops an appropriate care plan	Ahead of Expectations for Level of Training -- Appropriately modifies care plans based on clinical course and patient preferences	Exceptional: Special Skill Demonstrated -- Role models and comprehends complex, patient-centered care	Not Observed
b. Written Patient Record and Decision Making: Can synthesize a patient care plan and justify why urgent or emergent care is needed [EPA 7,10]

	Critical Deficiencies -- Attempts to perform procedures without sufficient skill or supervision	Improvement Needed -- Insufficient technical skill for safe completion of common procedures	Proficient: Meets Expectations for Levels of Training -- Possesses basic technical skill for the completion of common procedures	Ahead of Expectations for Level of Training -- Possesses good technical skill & has successfully performed procedures related to rotation	Exceptional: Special Skill Demonstrated -- Maximizes comfort and safety when performing procedures	Not Observed
c. Procedures: Possesses technical skill to successfully complete procedures relevant to the clinical rotation [PC, PBLI, EPA 11]

Medical Knowledge

	Critical Deficiencies -- Lacks scientific, socioeconomic or behavioral knowledge required to provide competent patient care	Improvement Needed -- Unable to demonstrate improved scientific, socioeconomic or behavioral understanding when faced with a similar scenario for a second time	Proficient: Meets Expectations for Levels of Training -- Possesses the scientific, socioeconomic and behavioral knowledge required to provide care for common medical conditions	Ahead of Expectations for Level of Training -- Possesses the scientific, socioeconomic and behavioral knowledge required to provide care for complex medical conditions	Exceptional: Special Skill Demonstrated -- Possesses scientific, socioeconomic and behavioral knowledge required to diagnose and treat uncommon, or complex conditions	Not Observed
a. Clinical Knowledge: Integrates clinical sciences with clinical application [MK1,2, EPA 7]

	Critical Deficiencies -- Misinterprets clinical and/or lab data, thereby causing misdiagnosis	Improvement Needed -- Often interprets normal findings as abnormal or vice-versa	Proficient: Meets Expectations for Levels of Training -- Acceptable level of analyzing clinical and lab data	Ahead of Expectations for Level of Training -- Able to synthesize clinical data and correlate them correctly with minimal preceptor input	Exceptional: Special Skill Demonstrated -- Able to function autonomously distinguishing normal and abnormal findings and correlating this with clinical and lab data	Not Observed
b. Problem Solving and Critical Thinking: Synthesizes and analyzes data correctly, correlates clinical and lab data, accurately determines active problems, distinguishes normal from abnormal findings [MK 8, EPAPA 3, 10]

	Critical Deficiencies -- Forms differential diagnoses not justified by clinical data, or unable to form a differential diagnosis	Improvement Needed -- Typically able to only come up with a rudimentary differential diagnosis	Proficient: Meets Expectations for Levels of Training -- Able to consistently form a small but correct differential diagnosis. (2-3 reasonable possibilities)	Ahead of Expectations for Level of Training -- Able to form a broad based and correctly prioritized differential diagnosis	Exceptional: Special Skill Demonstrated -- Needs no direction making an accurate & prioritized DDx w/ supporting evidence from H&P	Not Observed
c. Differential Diagnosis: Formulates a differential diagnosis, prioritizes it based on knowledge gathered [MK 9, EPAPA 2]

	Critical Deficiencies -- Lacks foundational knowledge to apply tests & procedures to patient care	Improvement Needed -- Inconsistently interprets basic diagnostic tests	Proficient: Meets Expectations for Levels of Training -- Consistently interprets basic diagnostic tests accurately	Ahead of Expectations for Level of Training -- Chooses testing wisely & accurately interprets complex diagnostic tests	Exceptional: Special Skill Demonstrated -- Anticipates and accounts for pitfalls and biases when interpreting tests and procedures	Not Observed
d. Knowledge of diagnostic testing and procedures [MK2, EPA 3]

Interpersonal & Communication Skills

	Critical Deficiencies -- Conveys inaccurate data that may pose detrimental	Improvement Needed -- Provides some relevant patient data but organization & flow impairs effectiveness	Proficient: Meets Expectations for Levels of Training -- Provides oral presentation with minimal prompting; typically accurate w/ history & exam	Ahead of Expectations for Level of Training -- Able to adapt style & length of presentation according to specialty & complexity of case	Exceptional: Special Skill Demonstrated -- Accurately & succinctly communicates in all clinical situations including admission, consultation & care hand-offs	Not Observed
a. Oral Case Presentation [IPC 2, 6, EPAPA 6,9]

	Critical Deficiencies -- Does not engage in shared decision-making or take preferences into account	Improvement Needed -- Respects patient preferences when offered, but does not actively solicit preferences	Proficient: Meets Expectations for Levels of Training -- Engages patients in shared decision making in uncomplicated conversations	Ahead of Expectations for Level of Training -- Incorporates patient preferences and shared decision making across a variety of patient care scenarios	Exceptional: Special Skill Demonstrated -- Role models effective communication and fosters therapeutic relationships in both routine & challenging situations	Not Observed
b. Communicates Effectively with Patients and Caregivers [EPA 9,11, IPCS 1,2,4]

	Critical Deficiencies -- Communication strategies hamper teamwork	Improvement Needed -- Uses unidirectional communication that fails to utilize wisdom of the team	Proficient: Meets Expectations for Levels of Training -- Sometimes engages in collaborative communication with team members	Ahead of Expectations for Level of Training -- Consistently engages in collaborative communication with team members	Exceptional: Special Skill Demonstrated -- Role models/teaches collaborative communication to enhance patient care, even in challenging settings	Not Observed
c. Communicates effectively in interprofessional teams (e.g. peers, consultants, nursing, and other professionals). [IPCS, EPAPA 8,9]

Practice-Based Learning and System Based Practice

	Critical Deficiencies -- Unwilling to self-reflect on practice or performance	Improvement Needed -- Lacks tools or misses opportunities to self-reflect on practice or performance	Proficient: Meets Expectations for Levels of Training -- Inconsistently self-reflects on practice performance & inconsistently acts upon reflections	Ahead of Expectations for Level of Training -- Regularly self-reflects on practice or performance & consistently acts upon those reflections	Exceptional: Special Skill Demonstrated -- Regularly self-reflects and seeks external validation to maximize practice improvement	Not Observed
a. Monitors practice with a goal for improvement [EPAPA 12, PBLI 1]

	Critical Deficiencies -- Never solicits feedback	Improvement Needed -- Rarely seeks, or sometimes responds to feedback in a defensive fashion	Proficient: Meets Expectations for Levels of Training -- Solicits feedback only from supervisors, usually incorporates feedback	Ahead of Expectations for Level of Training -- Solicits feedback from all members of the team and patients	Exceptional: Special Skill Demonstrated -- Performance continuously reflects incorporation of solicited and unsolicited feedback	Not Observed
b. Learns and improves via feedback [PBL 3, EPAPA 9]

Professionalism

	Critical Deficiencies -- Lacks empathy or compassion for patients & caregivers	Improvement Needed -- Inconsistently demonstrates empathy, compassion & respect for patients & caregivers	Proficient: Meets Expectations for Levels of Training -- Consistently respectful with patients, caregivers & members of team, even when challenging	Ahead of Expectations for Level of Training -- Demonstrates empathy, compassion & respect to patients and caregivers in all situations	Exceptional: Special Skill Demonstrated -- Role models compassion, empathy & respcect for patients and caregivers	Not Observed
a. Has professional and respectful interactions with patients, caregivers and members of the inter-professional team [Prof, EPAPA 9]

	Critical Deficiencies -- Sometimes dishonest in documentation, or scholarly activity	Improvement Needed -- Honest in clinical interactions, documentation, & scholarly activity.	Proficient: Meets Expectations for Levels of Training -- Honest & forthright in clinical interactions, documentation, and scholarly activity	Ahead of Expectations for Level of Training -- Demonstrates integrity, honesty, & accountability to patients, society & the profession	Exceptional: Special Skill Demonstrated -- Assists others in adhering to ethical principles of integrity, honesty, & professional responsibility	Not Observed
b. Exhibits integrity and ethical behavior in professional conduct [Prof, EPAPA 9]

Summary Comments*
Please include at least one area where student needs improvement, with specific examples. Also include observations about physical exam and histories.

Contributing Evaluation Form

Patient care

Medical Knowledge

Interpersonal & Communication Skills

Practice-Based Learning and System Based Practice

Professionalism