CASE PRESENTATION EVALUATION FORM

Day/Date
Resources Person
Case
Rotation
Group
No

CONTENTS

: ..............................................................................
: ..............................................................................
..............................................................................
: ..............................................................................
: ..............................................................................
: ..............................................................................

Description (Score 0-100)

Presentants
3
4

Opponents
8
9

History
Mention the emergency history related with
the problem
Physical Examination
2
Evaluate the primary survey found
Problem
3
Formulate the emergency problem
Explain the patogenesis and differential
4
diagnosis
Diagnostic plan
5
Planning additional examination needed
6
Explain the expected results
7
Explain the prior examination
Management
8
Explain the first drug treatment
9
Explain secondary survey
Mention the main complication and its
10
management
11
Determine time and reference purpose
Prognosis, Prevention and rehabilitation
12
Explain the prognosis
13
Explain how is the rehabilitation/prevention
Professionality
1

List Student (Presentants) :

1.

Resource Person
Signature

2.
3.
4.
5. .
List Student (Opponents) :
1.
2.
3.
4.
5. .
Comments: ..........................................................................................................................
............................................................................................................................................
............................................................................................................................................
............................................................................................................................................
............................................................................................................................................

10

PORTOFOLIO EXAMINATION EVALUATION FORM

Day /Date
Examiner

No

: ..............................................................................
: ..............................................................................
..............................................................................

Description

Score (0-100)
Student 1
Student 2

Primary Survey
Mention and explain the primary survey
1 results
A,B,C,D,E
Problem
Formulate the emergency problem
2
Management
Explain the early management done
3
4

Explain the monitoring needed

Secondary Survey
Mention and explain the secondary survey
5 results
(as the form provided)
Advanced management
Explain the additional examination and
6
the results expected
Determine time and reference purpose
7
Prognosis, Prevention and Rehabilitation
Explain the prognosis
8
Explain how the rehabilitation and
prevention
Proffesionality
9

Student Name :
1. ..............................................
2. ...............................................

Comment: ..
..
...
...

Examiner
Signature

4 th Stage Student Education

EMERGENCY MEDICINE CLINICAL PRACTICE MODULE
FACULTY of MEDICINE UI

1. PRIMARY SURVEY
1. Vital Signs Evaluation :
BP :

P:

RR :

T:

2. Airway Examination :
3. Breathing Evaluation :
4. Circulation Evaluation

5. Disability Evaluation

6. Exposure Evalution

2. PROBLEM EVALUATION

3. EARLY MANAGEMENT

4. SECONDARY SURVEY
Identity
Name
:
Age
:
Sex
:
Address :
Religion :
Occupation
:
Marriage Status :
Education
:

History

: (Autoanamnesis/Alloanamnesis:

relationship :

Main Complaint :
Current Illness History (including the examination results and treatment before):
Previous Illness History :
Family Illness History

Occupation, Social, Economy, Mental, and Habit History :

5. PHYSICAL EXAMINATION
1. Central Nervous System
2. Cardiovascular System
3. Respiratory System
4. Gastrointestinal System
5. Metabolic System
6. Infection System
7. Hematology System
6. PROBLEMS LIST
7. REVIEW
8. SUMMARY
9. PROGNOSIS

MORNING REPORT/TUTORIAL/DISCUSSION/CASE SIMULATION/EMERGENCY UNIT ROUND-COACHING *)

Day/Date
Resources Person
Topic

N
o.
1
2
3
4
5
6
7
8

: ........................................................
: ........................................................
: ........................................................

Rotation
Group

: Periode 1
:A

Group Members
Descriptiion

10

11

12

13

14

15

16

17

1
8

19

20

Give contribution in
formulation/explain the
problem
Ask question/gain
information
Inform/explain
Respect another person
opinion
Do not dominate the
group discussion and
the process
Actively participate in
group discussion
Present different
opinion politely
Actively listen
*)sctratch the unnecessary one

Note : 85-100 = very good (always); 75-85 = good (often); 60-75 = poor (rare); <60 = bad (never)
Students name:
1. Ari Basukarno
2. Ariel Pradipta
3. Denise Dewanto Setiawan
4. Eggi Respati
5. Riza Putri Aulia
6. Tommy Supit

7. Randolph N. T
8. Kresna D. S.
9. Alvin A. Sani
10. Karina Niken
11. Anindya Pradipta S.

Staff
Signature

MORNING REPORT/TUTORIAL/DISCUSSION/CASE SIMULATION/EMERGENCY UNIT ROUND-COACHING *)

Day/Date
Resources Person
Topic

N
o.
1
2
3
4
5
6
7
8

: ........................................................
: ........................................................
: ........................................................

Rotation
Group

: Periode 1
:A

Group Members
Descriptiion

10

11

12

13

14

15

16

17

1
8

19

20

Give contribution in
formulation/explain the
problem
Ask question/gain
information
Inform/explain
Respect another person
opinion
Do not dominate the
group discussion and
the process
Actively participate in
group discussion
Present different
opinion politely
Actively listen
*)sctratch the unnecessary one

Note : 85-100 = very good (always); 75-85 = good (often); 60-75 = poor (rare); <60 = bad (never)
Students name:
1. Ari Basukarno
2. Ariel Pradipta
3. Denise Dewanto Setiawan
4. Eggi Respati
5. Riza Putri Aulia
6. Tommy Supit

7. Randolph N. T
8. Kresna D. S.
9. Alvin A. Sani
10. Karina Niken
11. Anindya Pradipta S.
12. Em Aryo Winartomo
13. Ganesha Shamsudin

Staff
Signature

MORNING REPORT/TUTORIAL/DISCUSSION/CASE SIMULATION/EMERGENCY UNIT ROUND-COACHING *)

Day/Date
Resources Person
Topic

No
.
1
2
3
4
5
6
7
8

: ........................................................
: ........................................................
: ........................................................

Descriptiion

Rotation
Group

: Periode 1
: A1

Group Members
1

10

11

12

13

14

15

16

17

Give contribution in
formulation/explain
the problem
Ask question/gain
information
Inform/explain
Respect another
person opinion
Do not dominate the
group discussion and
the process
Actively participate in
group discussion
Present different
opinion politely
Actively listen

*)sctratch the unnecessary one

Note : 85-100 = very good (always); 75-85 = good (often); 60-75 = poor (rare); <60 = bad (never)
Students name:
1. Ari Basukarno
2. Ariel Pradipta
3. Denise Dewanto Setiawan
4. Eggi Respati
5. Riza Putri Aulia
6. Tommy Supit
7. Em Aryo Winartomo

Staff
Signature

1
8

19

20

MORNING REPORT/TUTORIAL/DISCUSSION/CASE SIMULATION/EMERGENCY UNIT ROUND-COACHING *)

Day/Date
Resources Person
Topic

No
.
1
2
3
4
5
6
7
8

: ........................................................
: ........................................................
: ........................................................

Descriptiion

Rotation
Group

: Periode 1
:A2

Group Members
1

10

11

12

13

14

15

16

17

Give contribution in
formulation/explain
the problem
Ask question/gain
information
Inform/explain
Respect another
person opinion
Do not dominate the
group discussion and
the process
Actively participate in
group discussion
Present different
opinion politely
Actively listen

*)sctratch the unnecessary one

Note : 85-100 = very good (always); 75-85 = good (often); 60-75 = poor (rare); <60 = bad (never)
Students name:
1. Randolph N. T
2. Kresna D. S.
3. Alvin A. Sani
4. Karina Niken
5. Anindya Pradipta S.
6. Ganesha Shamsudin

Staff
Signature

1
8

19

20

CASE PRESENTATION EVALUATION FORM

Day/Date
Resources Person
Case
Rotation
Group
No

:
:
:
:
:

..............................................................................
..............................................................................
..............................................................................
..............................................................................
..............................................................................

Description (Score 0-100)

History
Mention the emergency history related with
the problem
Physical Examination
Evaluate the primary survey found
2
Problem
Formulate the emergency problem
3
Explain the patogenesis and differential
4
diagnosis
Diagnostic plan
Planning additional examination needed
5
Explain the expected results
6
Explain the prior examination
7
Management
Explain the first drug treatment
8
Explain secondary survey
9
Mention the main complication and its
10
management
Determine time and reference purpose
11
Prognosis, Prevention and rehabilitation
Explain the prognosis
12
Explain how is the rehabilitation/prevention
13
Professionality
1

Presentants
5
4

10

11

12

13

Opponents
14
15
16

17

18

19

20

21

22

Students name:
Group A1
1. Ari Basukarno
2. Ariel Pradipta
3. Denise Dewanto Setiawan
4. Eggi Respati
5. Riza Putri Aulia
6. Tommy Supit
7. Em Aryo Winartomo

Group A2
8. Randolp N T
9. Kresna D. S.
10. Alvin A. Sani
11. Karina Niken
12. Anindya Pradipta S.
13. Ganesha Shamsudin

Comments: .............................................................................................................................
...............................................................................................................................................

Staff
Signature

Staff Evaluation Form

Instruction
Please evaluate honestly, objective, and fully responsible to your teacher. Your Information is
only be used to this module evaluation and will not affect your status as a student. Give score to
all aspects below by circle the number (1-5) on the column.
1 = very bad/ very low/never
2 = bad/low/rare
3 = poor/moderate/often
4 = good/high/often
5 = very good /very high/always
Staff Name
No.
1
2
3
4
5
6
7
8
9
10
11
12

: ________________________

Aspects
Able to explain the topics precisely
Able to give relevant example from the concept
teached
Able to explain the association between the topic
teached and another topic
Able to explain the association between the topic
teached and the life context
Mastering the latest issue of the topic teached
Use the research results to increase the
discussion quality
Able to light the discussion/lecture situation
Use the media and learning technology
Manage and disciplined the discussion/lecture
Give the material and answer the question in
discussion/lecture clearly
Material and the lecture/topic are appropriate
Give feed back on task

Comment :
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

MODULE EVALUATION SHEET

Give sign () to the column and also give your comment. Please evaluate honestly, objective,
and fully responsible because this evaluation will be used to improve the next emergency
medicine clinical practice module
No.
A
1

Activity
General
Student Guide Book

B
1
2

Exercise Phase
Introduction Lecture

3
4
5
6
7
8
9
10
11
12
13
14
15
16
17

C
18
19
20

L1.Clinical
Examination
L2.Introduction
to
Pediatric Emergency
L3. Introduction to
Medical Emergency
L4. Introduction to
Surgical Emergency
L5. Radiology
Introdution
Emergency Unit
Roud/Coaching
Emergency Unit Work
Morning Report
Case simulation
Case Presentation
Pharmacology &
Pharmacy Case
Presentation
Tutorial
Night Duty
Emergency Unit
round/Coaching in
associate hospital
Emergency Unit Work
in associate hospital
Morning report in
associate hospital
Feedback Phase
Log Book
Final Exam
Portofolio exam

Very Bad

Bad

Good

Very Good

Comment

CONTRIBUTORS
EMERGENCY MEDICINE MODULE
2010/2011

Dr. Rismala Dewi, SpA

Dr. Ceva Wicaksono, Sp.PD. KIC
Dr. Adisti Dwijayanti
Dr. Marcel Prasetyo, Sp.Rad
Prof. Dr. Amir Sjarif, SKM, SpFK
Dr. Cosphiadi Irawan, SpPD-KHOM
Dr. Arif Marsaban, SpAn
Dr. Lucky H. Moehario, Sp.MK PhD
Dr. Dohar AL Tobing, SpB
Dr. Ikhwan Rinaldi, SpPD
Dr. Piprim B Yanuarso, Sp.A
Dr. Muzal Kadim, Sp.A
Dr. R.A Setyo Handryastuti, Sp.AK