Koch Competency Assessment and Overall Grading Form
Resident (print name):
Based on the rating scale, CIRCLE how well the resident demonstrated the competencies listed below during the exam.
0 Poor: Failed to demonstrate knowledge / skill in this area.1 Fair: Demonstrated a minimal degree of knowledge / skill in this area.
2 Average: Average demonstration of knowledge / skill in this area,
but did not excel. / 3 Good: Demonstrated above average knowledge / skill
in this area.
4 Excellent: Excellent demonstration of knowledge / skill
in this area, clearly outstanding.
Competency / Poor / Fair / Average / Good / Excellent / N/A
Medical Knowledge / (circle your selection)
· Demonstrated investigatory and analytical thinking - - - - - / 0 / 1 / 2 / 3 / 4 / 5
· Knowledge and application of basic sciences ------/ 0 / 1 / 2 / 3 / 4 / 5
Practice-Based Learning and Improvement
· Assimilated evidence from scientific articles ------/ 0 / 1 / 2 / 3 / 4 / 5
Interpersonal and Communication Skills
· Appeared to organize thoughts before speaking ------/ 0 / 1 / 2 / 3 / 4 / 5
· Spoke clearly ------/ 0 / 1 / 2 / 3 / 4 / 5
· Focused / Targeted responses (i.e., did not ramble) / 0 / 1 / 2 / 3 / 4 / 5
· Checked and clarified information, if necessary ------/ 0 / 1 / 2 / 3 / 4 / 5
· Listened attentively ------/ 0 / 1 / 2 / 3 / 4 / 5
· Maintained good eye contact throughout ------/ 0 / 1 / 2 / 3 / 4 / 5
· Maintained good posture throughout ------/ 0 / 1 / 2 / 3 / 4 / 5
· Appeared confident, but not overconfident ------/ 0 / 1 / 2 / 3 / 4 / 5
Professionalism
· Commitment to ethical and moral decisions ------/ 0 / 1 / 2 / 3 / 4 / 5
· Received and responded well to our critiques ------/ 0 / 1 / 2 / 3 / 4 / 5
· Dressed appropriately ------/ 0 / 1 / 2 / 3 / 4 / 5
Systems-Based Practice
· Awareness of / responsiveness to larger system of health care ------/ 0 / 1 / 2 / 3 / 4 / 5
· Revealed that they would effectively call on system resources to provide care that is of optimal value ------/ 0 / 1 / 2 / 3 / 4 / 5
Continued on next page . . . .
Resident (print name):
Overall Strengths (list at least one strength displayed during oral exam):
Overall Weaknesses (list at least one weakness displayed during oral exam):
Evaluator 1 Print Name Evaluator 1 Signature
Evaluator 2 Print Name Evaluator 2 Signature Resident Signature
Date______
Please do not write below this line.
For Resident Office Personnel Use Only:
PGY Level: ____2 ____3 ____4
Percentage of correctly answered Oral Exam questions compared to PGY Level: ______%
Percentage of correctly answered Oral Exam questions compared to ALL Levels: ______%
Program Director’s Signature / Date….