Student Name: / Affiliation Dates:
Facility & Setting: / Clinical Instructor:

Please assess the student’s abilities and behaviors on each of the following criteria. Sample behaviors for the “Meets Expectation” rating are included with each criterion as examples of the program’s expectations for students. Comments are encouraged, as they provide valuable insight into the student’s strengths and weaknesses.

1. Safety: Practices in a safe manner that minimizes risk to patient, self and others.

Sample behaviors for the “Meets Expectations” rating:

  • Recognizes and responds to potential or real risks presented by patients.
  • Practices in a safe manner that minimizes risk to patient, self, and others.
  • Requests assistance when necessary.

Needs Improvement / Meets Expectations / Exceeds Expectations

Comments:

Area of Concern – if checked, please explain and then contact the DCE to discuss the concern.

2. Interpersonal & Communication Skills: Communicates in ways that are congruent with situational needs.

Sample behaviors for the “Meets Expectations” rating:

  • Effectively and respectfully communicates verbally and nonverbally with patients and staff (e.g. student introduces self).
  • Effectively seeks and responds to constructive feedback.
  • Adjusts communication style based on audience (e.g. language, level of education, cognitive impairment, cultural differences).

Needs Improvement / Meets Expectations / Exceeds Expectations

Comments:

Area of Concern – if checked, please explain and then contact the DCE to discuss the concern.

3. Professional Behavior: Demonstrates professional behavior in all situations.

Sample behaviors for the “Meets Expectations” rating:

  • Effectively uses time and resources.
  • Adheres to legal and ethical standards.
  • Demonstrates initiative (e.g. arrives well prepared, offers assistance, seeks learning opportunities).

Needs Improvement / Meets Expectations / Exceeds Expectations

Comments:

Area of Concern – if checked, please explain and then contact the DCE to discuss the concern.

4. Patient Care: Performs a patient examination and intervention with assistance.

Sample behaviors for the “Meets Expectations” rating:

  • Assists with patient examination.
  • Performs a chart review.
  • Performs patient history.
  • Chooses best tests and measures.
  • Identifies body structure and function impairments.
  • Identifies measurable time-based goals.
  • Assists with patient interventions.
  • Recognizes indications, precautions, and contraindications to interventions.
  • Prioritizes interventions.
  • Administers interventions under supervision.
  • Modifies interventions based on patient response.

Needs Improvement / Meets Expectations / Exceeds Expectations

Comments:

Area of Concern – if checked, please explain and then contact the DCE to discuss the concern.

5. Problem Solving: Applies current knowledge, theory, clinical judgment, and the patient’s values and perspectives inpatient management.

Sample behaviors for the “Meets Expectations” rating:

  • Synthesizes examination data to determine simple physical therapy diagnosis and prognosis, with guidance.
  • Utilizes information from multiple data sources to make clinical decisions (e.g. patient, clinical instructor, evidence, didactic coursework).
  • Presents a logical rationale for clinical decisions.

Needs Improvement / Meets Expectations / Exceeds Expectations

Comments:

Area of Concern – if checked, please explain and then contact the DCE to discuss the concern.

Overall comments:

Clinical Instructor:
Signature / Date
Student:
Signature / Date