Brody School of Medicine – M4 Medical Student Evaluation Form

Student’s Name
Course Title
Course Number
Course Date
Course Director
Institution/Location
H: Exceptional; A: Above expectations; B: Meets expectations; C: Below expectations; F: Unacceptable; I: Extension approved by Course Director
If you circle C or F please provide specific comments in the spaces provided
Skill or Behavior / (Circle One) / Optimal Performance
Patient Care / Care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health
History-taking / H / A / B / C / F / Identifies, pursues, and characterizes all problems in reasonable time; records are logically developed, cogent, organized, and of appropriate length
Procedural Skills / H / A / B / C / F / Demonstrates proficiency in procedures appropriate to rotation, including use of equipment. Demonstrates a patient-centered approach, reflecting respect for patient privacy, comfort and safety
Physical examination / H / A / B / C / F / Technically competent; suitably thorough; reasonable time; findings related to problems; record orderly and detailed
Clinical sources / H / A / B / C / F / Obtains, records, and uses all available information from clinical sources; interprets in relation to patient's problems
Medical Knowledge / Knowledge of established and evolving biomedical, clinical, and cognate sciences and the application of this knowledge to patient care
Amount of Factual Knowledge / H / A / B / C / F / Demonstrates mastery of facts and concepts appropriate to the rotation. Employs knowledge fund to develop and support the differential diagnosis, identified gaps in personal knowledge fund and works to remedy them
Differential diagnosis / H / A / B / C / F / Groups all patient problems into reasoned differential diagnosis; rationale & plan to confirm diagnoses regularly demonstrate knowledge of pathophysiology
Treatment program / H / A / B / C / F / Identifies current & past treatment and potential drug allergies; formulates appropriate treatment plan; shows sound knowledge of pharmacology; recognizes need for urgent treatment and initiates appropriate action
Practice-Based Learning & Improvement / Investigation and evaluation of their own patient care, appraisal and assimilation of scientific evidence, and improvements in patient care
Academic sources / H / A / B / C / F / Extensively uses academic sources, including journals to study patient's specific problems; findings communicated and used to make clinical decisions
Follow patient's progress / H / A / B / C / F / Continuously monitors patient; reviews all clinical data; reassesses need for additional information or management, including rationales; follows through appropriately
Interpersonal & Communication Skills / Effective information exchange and teaming with patients, their families, and other health professionals
Verbal reports / H / A / B / C / F / Communicates clearly and succinctly; information complete, organized, synthesized, & includes rationale
Doctor-patient relationship / H / A / B / C / F / Reassuring, caring, supportive, and accurate; relationships with patients engender confidence; communications with patients are effective, efficient, and educational
Systems-Based Practice / Actions that demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to call effectively on system resources to provide care that is of optimal value
Efficacy, quality and safety / H / A / B / C / F / Selects therapies and interventions with costs in mind; identifies patients with limited resources for appropriate assistance; recognizes system-wide implementation of best practice (quality) and elimination of medical errors (safety) and opportunities for implementation of such policies
Comments:
3 = No Issues whatsoever 2 = Some concern about this issue 1 = definitely a problem
Professionalism / A commitment to carrying out professional responsibilities, adhering to ethical principles, and showing sensitivity to a diverse patient population
Integrity and Trustworthiness / 3 / 2 / 1 / Unable to rate / Displays honesty and forthrightness; adheres to ethical standards; truthful in all communications; maintains confidentiality; reports inappropriate behavior by colleagues
Compassion and Respect for Others / 3 / 2 / 1 / Unable to rate / Considerate; cooperative; displays empathy; respectful of different socioeconomic backgrounds & cultural traditions; sensitive; respects authority
Teamwork & Professional Demeanor / 3 / 2 / 1 / Unable to rate / Works well with others; maintains composure in difficult circumstances; inspires trust; avoids inappropriate remarks, adheres to local dress codes
Responsibility & Sense of Duty / 3 / 2 / 1 / Unable to rate / Completes assigned duties; sets and achieves realistic goals; follows policies; responds promptly when called; detail-oriented; places patient needs first
Accountability & Initiative / 3 / 2 / 1 / Unable to rate / Flexible; delegates effectively; accepts personal responsibility for mistakes; asks for help when needed; discloses medical errors when appropriate
Scholarship & Commitment to Learning / 3 / 2 / 1 / Unable to rate / Punctual; attends classes, clinics, other required events; seeks additional knowledge & skills; seeks feedback; willing to assist other learners
Concern for the Welfare of Patients / 3 / 2 / 1 / Unable to rate / Treats patients and families with dignity; respects patient privacy; maintains accurate information in patient records; advocates for patients
Self-Care & Self-Growth / 3 / 2 / 1 / Unable to rate / Maintains personal health and hygiene; seeks advice, counsel, or tutoring when needed; avoids harmful behaviors
If you selected a rating of 2 or 1 for any professionalism item, please provide specific comments in the space below:

Grade
Course Director’s Name: Signature : Date
Return this form to: Brody Student Affairs / / Fax-252-744-3250 or 600 Moye Blvd, Mail Stop 613, Greenville, NC 27834