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Clinical Supervisor's Report Are you the clinical supervisor?

m Yes k n j l

m No k n j l

Name of Foundation Doctor: GMC Number: Training period: Hospital/GP/Other: Specialty:

Questions
Professionalism, probity and health As far as you are aware, how many days has this doctor been absent from work? (do not include annual leave or study leave)

Do you have any concerns about this doctor s professionalism or probity?

m Yes k n j l

m No k n j l
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If yes please state your concerns


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Do you have any concerns about this doctor s health?

m Yes k n j l

m No k n j l
5

If yes please state your concerns


6

Good clinical care How do you rate this doctor s ability to take a history and examine a patient? m k n j l Unsatisfactory performance m k n j l Poor performance m k n j l Satisfactory m k n j l Good m k n j l Very Good m k n j l Excellent m k n j l Unable to comment

How do you rate this doctor s clinical decision making? m k n j l Unsatisfactory performance m k n j l Poor performance m k n j l Satisfactory m k n j l Good m k n j l Very Good m k n j l Excellent m k n j l Unable to comment

How do you rate this doctor s ability to prescribe safely and effectively? m k n j l Unsatisfactory performance m k n j l Poor performance m k n j l Satisfactory m k n j l Good m k n j l Very Good m k n j l Excellent m k n j l Unable to comment

How do you rate this doctor s medical record keeping? m k n j l Unsatisfactory performance m k n j l Poor performance m k n j l Satisfactory m k n j l Good m k n j l Very Good m k n j l Excellent m k n j l Unable to comment

How do you rate this doctor s ability to recognise and manage the acutely ill patient? m k n j l Unsatisfactory performance m k n j l Poor performance m k n j l Satisfactory m k n j l Good m k n j l Very Good m k n j l Excellent m k n j l Unable to comment

How do you rate this doctor s ability to manage chronic diseases? m k n j l Unsatisfactory performance m k n j l Poor performance m k n j l Satisfactory m k n j l Good m k n j l Very Good m k n j l Excellent m k n j l Unable to comment

How do you rate this doctor s ability to plan for discharge?

m k n j l Unsatisfactory performance

m k n j l Poor performance

m k n j l Satisfactory

m k n j l Good

m k n j l Very Good

m k n j l Excellent

m k n j l Unable to comment

Maintaining Good Medical Practice How do you rate this doctor s ability to use evidence and guidelines to improve patient care? m k n j l Unsatisfactory performance m k n j l Poor performance m k n j l Satisfactory m k n j l Good m k n j l Very Good m k n j l Excellent m k n j l Unable to comment

Relationships with Patients How do you rate this doctor s ability to communicate with patients? m k n j l Unsatisfactory performance m k n j l Poor performance m k n j l Satisfactory m k n j l Good m k n j l Very Good m k n j l Excellent m k n j l Unable to comment

How do you rate this doctor s ability to communicate with carers and / or family? m k n j l Unsatisfactory performance m k n j l Poor performance m k n j l Satisfactory m k n j l Good m k n j l Very Good m k n j l Excellent m k n j l Unable to comment

Working with Colleagues How do you rate this doctor s ability to work with colleagues? m k n j l Unsatisfactory performance m k n j l Poor performance m k n j l Satisfactory m k n j l Good m k n j l Very Good m k n j l Excellent m k n j l Unable to comment

Teaching and Training How do you rate this doctor s effectiveness when teaching colleagues? m k n j l Unsatisfactory performance m k n j l Poor performance m k n j l Satisfactory m k n j l Good m k n j l Very Good m k n j l Excellent m k n j l Unable to comment

Overall rating How do you rate this doctor at the end of the placement compared to a doctor ready to complete F1/F2? m k n j l Unsatisfactory performance m k n j l Poor performance m k n j l Satisfactory m k n j l Good m k n j l Very Good m k n j l Excellent m k n j l Unable to comment

Any other comments


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