| OUTPATIENT CLINIC M3
STUDENT EVALUATION |
| Name |
Date |
Evaluator |
| Name of clinic |
| M3: You should
give this evaluation form to the one person you worked mostly with
during clinic for each clinic you are assigned for Obstetrics and
Gynecology (Do not give this form for Gyn
Onc clinics).
Please be sure that you write your name down, the date, and
the name of the person you are giving the evaluation to before
you hand it to them. By
the end of the clerkship you should have 10-15 completed evals
depending on the amount of clinics you are assigned. |
| Evaluators:
Please circle that group of phrases that you believe best describes
the student's performance in each of the following areas of
evaluation. At the end,
please add written comments that you feel are appropriate to further
describe the student's performance.
Please be sure to return the evaluations to the clerkship
coordinator. |
| Category |
Evaluation Rating |
| Basic Women's Health Care |
Fine grasp of routine women's health care.
Knows major issues , and
some fine points. |
Knows major issues of basic women's healthcare. |
Deficient knowledge of major issues in women's health
care. |
Inaccurate or major omissions in knowledge of basic
women's health |
Not Observed |
| Patient Triage |
Accurately assesses patients' level of acuity and
prioritizes patients by degree of illness |
Assessment of acuity mostly accurate, can reliably
distinguish between emergent and non-emergent patients |
Distinguishes emergently sick patients with
difficulty. |
Unreliable or inconsistent judgment. |
Not Observed |
| Pelvic Exam |
Experienced no obvious difficulties, explanations
given to patient at all times throughout the exam |
Completed with minimal direction, explained to patient
most of what he/she was doing during the exam |
Exam completed with assistance, needed reminder to
provide explanation to patient during exam. |
Student did not know how to complete this exam without
direction. Student
didn't give any explanation of exam to the patient. |
Not Observed |
| Breast Exam |
Experienced no obvious difficulties, explanations
given to patient at all times throughout the exam |
Completed with minimal direction, explained to patient
most of what he/she was doing during the exam |
Exam completed with assistance, needed reminder to
provide explanation to patient during exam. |
Student did not know how to complete this exam without
direction. Student
didn't give any explanation of exam to the patient. |
Not Observed |
| OB Patient Exam |
Experienced no obvious difficulties, explanations
given to patient at all times throughout the exam |
Completed with minimal direction, explained to patient
most of what he/she was doing during the exam |
Exam completed with assistance, needed reminder to
provide explanation to patient during exam. |
Student did not know how to complete this procedure
without direction. |
Not Observed |
| Initial History/Interviewing Skills |
Resourceful, efficient, appreciates subtleties,
insightful, obtains all relevant data including psychosocial
components |
Precise, detailed, broad-based, obtains almost all
relevant data including psychosocial components |
Obtains basic history, obtains most of the relevant
data and most of the psychosocial components |
Incomplete or unfocused, relevant data missing,
psychosocial components absent or sketchy |
Not Observed |
| Oral Presentations |
Tailored to situation, succinct but complete |
Fluent, focused, maintains format, includes all basic
information, minimal use of notes. |
Minor omissions, included to many irrelevant facts,
did not follow format, relied on notes. |
Major omissions, included many irrelevant facts,
rambling, format not followed. Heavily relied on notes. |
Not Observed |
| Data Interpretation and Knowledge |
Understands and presents complete problem list and
differential diagnosis, able to independently prioritize issues,
provides thorough plan for further evaluation and/or treatment |
Understands basic problem list and offers reasonable
differential diagnosis, is able to offer some therapeutic options or
follow-up. |
At a level that understands problem list, with
assistance formulates differential, needs assistance in formulating
a plan. |
Marginal understanding of clinical problems, unable to
prioritize or offer reasonable differential or treatment plan. |
Not Observed |
| Interpersonal Skills/Professionalism |
Consistently elicits and deals with patient's
emotional and personal problems in sensitive and skillful manner,
consistently respectful of entire health care team (nurse, etc.) |
Addresses patient's emotional and/or personal
problems, courteous to entire team. |
Inattentive to patient's emotional and/or personal
problems, cooperative with staff. |
Missed assessing patients' emotional or personal
problem, showed lack of consideration to health care team members. |
Not Observed |
| Psychomotor |
Student's motor
skills were exceptional |
Student's motor
skills were acceptable |
Students motor
skills need some improvement |
Student's motor
skills were unacceptable. |
Not Observed |
| Reliability/Availability/
Attitude |
Student was always available to nursing staff,
residents, & Faculty. Student
obviously interested. |
Student was available most of the time to assist the
nursing staff, residents, and faculty.
Student appeared interested. |
Student was not easily located to assist the nursing
staff, resident, and faculty. Student
showed some disinterest. |
Student did not make him/herself available to nursing
staff, residents, or faculty. Obvious
disinterest in OB/GYN. OR
no call/no show to clinic |
Not Observed |
| COMMENTS ON OUTSTANDING OR UNSATISFACTORY
RATINGS:
|
| Evaluator
Signature:___________________________________ |