Evaluated By : ______________________________________________

Evaluating
: ______________________________________________
Dates
: ______________________________________________

Frank H Netter SOM

Yr3 ObsGyn

* indicates a mandatory response

CLERKSHIP FACULTY ASSESSMENT OF STUDENT

Site:

For each category below, please select the appropriate level of ability (1-5). Qualities/behaviors should be cumulative as rating increases, e.g.
a 5 for physical exam skills assumes that major findings are identified in an organized, focused manner AND that subtle findings are
elicited. Indicate the level at which the student consistently performs.
1

Lacks ability
to interpret
Significant
Not
data,
deficiencies
Observed
demonstrates
in
or Not
marginal
knowledge
Applicable
understanding
base
of common
diseases

Demonstrates
understanding of
common diseases,
including etiologies,
basic
pathophysiology,
diagnostic tests,
and basic
therapeutics

Demonstrates
thorough
understanding
of diagnostic
approach;
consistently
able to
interpret data

In-depth
understanding of
medical
knowledge,
pathophysiology,
and application
to clinical care

MEDICAL KNOWLEDGE
2

Efficiently gathers
detailed,
accurate, medical
histories from
patients and
families including
health risk
behaviors.

Resourceful in
gathering
thorough
medical
histories,
appreciating
subtleties
necessary for
management.

Not
Observed
or Not
Applicable

Disorganized
and unable to
gather
accurate,
relevant
medical
histories from
patients and or
families

Not
Observed
or Not
Applicable

Unreliable
exam;
misses
major
findings,
insensitive
to patient
comfort

Incomplete
or inaccurate
physical
and/or
mental
status
examination
findings

Performs an examination
appropriate for the
patient's presenting
symptoms and signs and
accurately identifies major
physical and/or mental
status examination
findings

Organized,
focused, and
relevant
physical
and/or mental
status
examination
findings

Additionally,
elicits
subtle
findings

Often gathers
inconsistent
and
incomplete
medical
histories from
patients and
or families

Active
listener; who
accurately
obtains a
basic history
and identifies
patient
concerns.

PATIENT CARE
History Taking Skills

Physical and Mental Status Exam Skills

1

Not
Observed
or Not
Applicable

Disorganized in
both preparation
and
presentation.
Often with major
omissions and
inaccurate
reporting of
information

Information
present,
however
with
frequent
gaps in
flow,
chronicity
and
findings

Accurately uses both

oral & written
presentation formats
appropriate for clinical
setting, including all
basic information; If
applicable,
appropriately uses EMR

Fluent
reporter.
Provides
concise
information
leading to
early
delineation
of the
patient
problem

Able to tailor
presentation
to clinical
situation
reflecting a
thorough
understanding
of patient
condition

Oral/Written Presentation Skills

Page 1

Unaware of
indications,
contraindications
Not
and potential
Observed complications of
or Not
procedures.
Applicable
Unable to
perform basic
procedures at
expected level

Limited
understanding of
indications,
contraindications
and potential
complications of
procedures.
Engages in
performing basic
procedures but
unable to
consistently
perform the
procedures
successfully.

Knows
indications,
contraindications
and potential
complications of
procedures.
Engages patient
in informed
consent process.
Able to
successfully
perform basic
procedures
safely, under
direct
supervision.

Demonstrates
an advancing
skill set in
performing
basic
procedures.

Ready to
perform basic
procedures
independently

Procedural Skills
1

Frequently
reports data
Cannot interpret
without
basic data;
analysis;
problem lists
problem lists
inaccurate/not
need
updated; Unable improvement.
Not
to create a
Inconsistent
Observed
diagnostic and
prioritization
or Not
management
of clinical
Applicable
plan; Fails to
issues
recognize
Difficulty with
potentially life
creating a
threatening
diagnostic
problems
and
management
plan

Uses clinical
data to
formulate
reasonable
differential
diagnoses;
which include
both common
and life
threatening
conditions.
Contributes to
logical
diagnostic and
management
plan

Develops
and justifies
expanded
differential
diagnoses,
detailed
diagnostic
and
management
plans.
Considers
cultural and
psychosocial
issues

Understands
complexities of
patient problems
and develops a
comprehensive
management plan,
Recognizes disease
presentations that
deviate from
common pattern,
develops
customized,
prioritized care
plans including
counseling
incorporating
diagnostic
uncertainty and cost
effectiveness
principles.

Clinical Reasoning, Problem Solving

and Management
1

Not
Observed
or Not
Applicable

Frequently
does not
demonstrate
truthful and
respectful
interactions
with team
members

At times
does not
demonstrate
truthful and
respectful
interactions
with team
members.

Understands role of
student in healthcare
team; always truthful
and respectful in
personal interactions
with team members.
Mindful of demeanor,
language and
appearance.

Models
behaviors to
improve
interactions
with health
care team on
the path to
becoming a
role model

Acts as a role
model in a
collegial,
compassionate
and respectful
manner

PROFESSIONALISM AND ETHICS

Professional Behaviors as a Medical
Student and Member of a Health Care
Team

Page 2

Not
Observed
or Not
Applicable

Frequently does
not take ownership
in role of patient
care. Frequently
does not prioritize
needs of patient
above those of
self.

At times does not

take ownership
in role of patient
care. Difficulty
prioritizing needs
of patient above
those of self.

Accepts
ownership of
their roles in
patient care;
Actions reflect
commitment to
best interest of
the patient.

Appropriately
displays a
higher level
of
responsibility.
An active
participant in
patient care

Accepts
personal
ownership
in patient
care; Seen
by patient
as a trusted
member
of
healthcare
team; seen
as a role
model for
patient
care

Professional Behaviors Related to

Patient Care
1

I have serious concerns about

this student's ethical behavior
(click for definition)

I have occasional concerns about

this student's ethical behavior
(click for definition)

I have no concerns about this

student's ethical behavior
(click for definition)

Ethics (see definition of ethical

behavior)
1

Avoids
patient or
Not
family
Observed
interaction,
or Not
tactless,
Applicable
rude,
disrespectful

Occasionally
insensitive,
inattentive,
or
judgmental

Sympathetic,
respectful, develops
rapport, gains trust;
treats patients and
families with respect,
equality and without
bias

Consistently
elicits and
respects
point of
view of
patient

Able to interact
effectively with
challenging
personalities.
Establishes tone
of mutual respect
& dignity.

Consistently
seeks out
collaboration
with other
health care
professionals
and staff

Able to interact
effectively with
challenging
personalities.
Establishes tone
of mutual
respect &
dignity.

INTERPERSONAL COMMUNICATION
Interactions with Patients and Families
1

Lack of
consideration
Not
Antagonistic
for others,
Observed
or
unaware of
or Not
disruptive
their role in
Applicable
the health
care team.

Cooperative,
productive member
of healthcare team;
Treats other
professionals and
staff with respect,
equality and without
bias

Interactions with Health Care

Professionals and Staff

Page 3

Frequently
At times does
does not
not engage in
engage in
selfselfassessment
assessment
and seeking
and seeking
feedback
feedback
from others
from others
to identify
to identify
areas for
areas for
improvement.
improvement.
Does not
Not
Does not
identify
Observed
identify
resources to
or Not
resources to
improve
Applicable
improve
performance. performance.
Does not
Does not
apply new
apply new
knowledge
knowledge
and skills
and skills
including
including
evidence
evidence
based
based
medicine to
medicine to
patient care.
patient care.

Engages in selfassessment and seeks

feedback from others
to identify areas for
improvement;
Identifies resources to
improve performance;
Applies new
knowledge and skills
including evidence
based medicine to
patient care.

Consistently Demonstrates
demonstrates excellence in
selfselfassessment
assessment
and seeking
and seeking
feedback
feedback
from others
from others
to identify
to identify
areas of
areas of
improvement. improvement.
Identifies
Identifies best
best
evidenced
evidenced
based
based
resources to
resources to
improve
improve
performance.
performance.
Utilizes new
Applies new
knowledge
knowledge
and skills to
and skills
facilitate the
including
education of
evidence
self and
based
others to
medicine to
improve
patient care
patient care.

PRACTICE BASED LEARNING AND

IMPROVEMENT
Self-Directed/ Independent Learning

Not
Observed
or Not
Applicable

Unable to
identify
needs and
resources for
patients.
Lacks
awareness of
healthcare
costs.
Unable to
utilize
resources
needed for
patient
discharge
and follow up
planning.

At times fails to
identify needs
and resources
for patients.
Lacks full
awareness of
healthcare
costs.
Has limited
knowledge of
community
resources to
facilitate safe
patient
discharge and
follow up
planning.

Able to identify
needs and
resources for
patients.
Demonstrates
awareness of
healthcare
costs.
Has an
awareness of
needed
community
resources in
discharge and
follow up
planning.

Consistently able to
identify needs and
resources for
patients.
Demonstrates
awareness of
healthcare costs at
a systems level.
Is able to utilize
community
resources in
discharge and follow
up planning

Always able
to identify
needs and
resources
for patients.
Advocates
for systems
changes
that can
benefit
health care
populations.

SYSTEMS BASED PRACTICE

Utilization of Health Care Delivery
System for Patient Care
DESCRIPTIVE COMMENTS: (Written descriptive comments are required for each student to help distinguish their performance and provide
them with useful/feedback.

*1. What are this student's strength's (please provide specific descriptions)

*2. What could this student improve upon? (please provide specific descriptions and suggestions for improvement

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The following will be displayed on forms where feedback is enabled...

(for the evaluator to answer...)
*Did you have an opportunity to meet with this trainee to discuss their performance?
Yes
No

(for the evaluee to answer...)

*Did you have an opportunity to discuss your performance with your preceptor/supervisor?
Yes
No

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