RESIDENTSNAME:

PGY LEVEL: 123 4 5

MEDICALSTUDENT EVALUATIONOF SURGICAL RESIDENT

PracticeDomainCompetencyCriticalDeficienciesLEVEL1LEVEL2LEVEL3LEVEL4

CareforDiseasesandConditions(CDC)

PatientFamilyeducation

INTERPERSONAL COMMUNICATIONSKILLS(ICS1)

This residentisnotableto clearly,accurately,andrespectfullycommunicate withpatients and families.

This residentfailstoeffectivelycommunicatebasic healthcareinformationto patientsandfamilies.

This residentusesa varietyoftechniques, includingnon-technicallanguage, teachback,appropriate pacing,andsmall pieces of informationtoensurethat communicationwithpatientsand theirfamiliesisunderstandableandrespectful.

This residenteffectivelycommunicatesbasic healthcare information topatientsand families.

This residentcustomizescommunication, takingintoaccountpatientcharacteristics(e.g.age,literacy, cognitivedisabilities).

This resident providestimely updatestopatientsandfamiliesduring hospitalizations.

This residentcannegotiate andmanageconflictamongpatients,families,andcareproviders.

This residentcancustomizeemotionallydifficultinformation,such as endoflife discussions.

Comments:Insufficientcontenttojudge

PracticeDomain / Competency / CriticalDeficiencies / LEVEL1 / LEVEL2 / LEVEL3 / LEVEL4
CareforDiseasesandConditions(CDC)
Teamplayer,Hand-offsandOwnership / INTERPERSONAL COMMUNICATIONSKILLS(ICS1) / This residentdisplaysdisrespectfulorresentfulbehaviorswhen askedto evaluatea patientorparticipatein acareconferencewithothermembers ofthehealth care team / This residentwillingly exchangespatientinformationwithteammembers
This residentrespondspolitely and promptlytorequestsforconsultsandcarecoordinationactivities
This residentperforms face-to-facehand-offs / This residentexhibitsbehaviors(e.g.respect,approachability, listens)thatinvite informationsharing withhealthcareteammembers
This residentperformshand-offbestpractices,e.g.usesmultiple formsof informationtransfer,confirmsreceipt ofinformation,invites questions / This residentdiscussescare planswiththeteamandkeepsthemuptodateonpatient status and careplanchanges
This residentnegotiatesand manages conflictamongcare providers
This residenttakesresponsibilityforensuringthat clearhand-offs aregiven attransitionsofcare / This residentassumesoverallleadership of ahealthcare teamresponsibleforhis/herpatients,while at thesame timeseekingandvaluing
inputfrom themembersof the team
This residentinitiatesdiscussionwith careprovidersto resolvedifferencesin thecareplan

MEDICALSTUDENTEVALUATIONOF RESIDENT

PracticeDomain / Competency / CriticalDeficiencies / LEVEL1 / LEVEL2 / LEVEL3 / LEVEL4
MaintenanceofPhysicalandEmotionalHealth(MPEH)
ManagementofDutyhoursand fatigue / PROFESSIONALISM(PROF2) / This resident'sbehaviorand/orphysicalconditionconcernme
This residentflagrantlyandrepeatedlyviolatesduty hourrequirements / Theresidentisawareofthedutyhourslimitationsforthisprogram / This residentrecognizes thesymptomsoffatigue,andunderstandstheconsequencesof sleepdeprivation;(s)hemonitorshis/her ownfatigueandstress,moderatesbehavioraccordingly, and seekssupportwhennecessary forexcessive fatigueorstress / This residenteffectivelymanageshis/hertimeandassuresfitness forduty
This residentsetsanexamplebypromotinghealthy habitsandcreatinganemotionallyhealthy environment forthoseworking withhim/he / Theresidentcreatesahealthy workenvironmentandisproactive inmodifying schedulesorinterveningin otherways(e.g.require nap, counsel,referto services,report to programdirector)to assurethatthose caregiversunderhis/hersupervisiondo notcompromisepatient
safety
Comments: / Insufficientcontenttojudge

Copyright©2013TheAccreditationCouncilfor Graduate MedicalEducation andTheAmericanBoardof Surgery.Allrights reserved. Thecopyright owners

PracticeDomain / Competency / CriticalDeficiencies / LEVEL1 / LEVEL2 / LEVEL3 / LEVEL4
SelfDiscipline / PROFESSIONALISM(PROF3) / Doesnot careoracknowledgeforstudents
Teachingis thelastpriority
Uses studentstodohis scut work.
Rotationwasa wastebecauseof thisresident / Goodteacherwhenhe/shehas timeStudentsarenot thepriority / Hasestablishedteachingandlearningasapriority ontheservice.
Ilefteveryday havinglearntmorebecauseof thisresident. / Hasestablishedteachingschedules forstudentsTreatsstudents withrespect anddignity
Ihavegained anewrespect forsurgerybecauseof thisresident / AlwaysontimeandisaRolemodel forresidency
Brings students toalldidactics.
Maintains Professionaldress-codeandinsistsonstudents todothesame
Calls students forallbedsideroundswithattending
Teaches at everyopportunity
Insufficientcontenttojudge
Comments:

Name ofthe student(Optional)Date

ResidentSignatureDate

Clerkship DirectorSignatureDate

PresentedtoCoreCurriculumSubcommittee

Copyright©2013TheAccreditationCouncilfor Graduate MedicalEducation andTheAmericanBoardof Surgery.Allrights reserved. Thecopyright owners