Fourth Year Medicine Elective Student Evaluation Form

UH John A. Burns School of MedicineDepartment of MedicineFourth-Year Medicine ElectiveStudent Evaluation FormStudent: ______________________________________________Course number: MED _________- _____Block: ____ Dates of Elective: _________________________ Elective: __________________________________Date of this report: ____________________________________Site: ______________________________________ExceptionalVery CompetentCompetentMarginalUnsatisfactoryNot EvaluatedI. Life-Long Learning SkillsGraduates will be life-long learners.• Demonstrates enthusiasm, motivation and self-initiative to learn• Identifies relevant learning issues, searches for and critically appraises information(self-directed learning)Comments:II. The Biological SciencesGraduates will understand the biological sciences underlying clinical medicine.• Demonstrates basic science knowledge (including anatomy, physiology, pathologyand pathophysiology)• Demonstrates clinical knowledge (including knowledge of the illnesses seen in theadult patient/population in Hawaii, Asian-Pacific region and globally)• Applies basic science knowledge to clinical situationsComments:III. The Care of PatientsGraduates will be able to care for their patients under the supervision of faculty.• Demonstrates respect and compassion for patients and their families• Interviews patients in a systematic, organized and thorough manner(History Taking)• Examines patients in a systematic, organized and thorough manner(Physical Exam)• Formulates appropriate Assessments, Problem Lists and Differential Diagnoses• Formulates appropriate Diagnostic Plans• Formulates appropriate Therapeutic Plans• Applies evidence based medicine (EBM) methodology to patient care• Educates and counsels patients and their families about health, illness and theprevention of illness• Demonstrates clinical judgment and problem solving skills• Works efficientlyComments:Revised 7/18/11 1

ExceptionalVery CompetentCompetentMarginalUnsatisfactoryNot EvaluatedIV. Oral and Written Communication SkillsGraduates will be able to communicate effectively with patients, families and otherhealthcare providers.• Uses effective verbal and non-verbal communication skills (including listeningand using language appropriate for each patient, family and clinical setting)• Presents cases in a systematic, organized manner that is accurate and appropriate forthe clinical setting• Writes notes (write-ups and progress notes, etc) in a systematic, organized mannerthat is accurate, legible and appropriate for the clinical settingComments:V. ProfessionalismGraduates will be professional and ethical, demonstrate an enthusiasm for medicine, andvalue honor, integrity, altruism, respect, accountability, excellence, scholarship, andleadership while delivering compassionate care to their patients.• Demonstrates professional relationships with others (attendings, residents, students,nurses, other health care workers, patients and their families)• Works as an effective team member• Attends all required clerkship and training site-specific activities; is punctualand attentive; actively participates• Seeks, accepts and responds to feedback• Demonstrates professional appearance, attire and behavior• Demonstrates altruism and serves as a patient advocateComments:Other Comments:Elective Preceptor’s Name: ______________________________ Signature: ______________________ Date: ___________Student’s Signature: ____________________________________Date: ___________~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~For UH Department of Medicine use only:Course Director: Laurie M. Tam, M.D.Signature: ______________________ Date: ___________Course number: MED ________- _____ Course name: __________________ Grade: Credit __ No Credit __ Incomplete __Revised 7/18/11 2

U.H. John A. Burns School of MedicineDepartment of MedicineStudent Evaluation FormRatings DefinitionsEXCEPTIONAL:The student consistently demonstrates medical knowledge, clinical skills or professionalism at a level higher thanexpected for a fourth year student. In other words, the student consistently “goes the extra mile” and performs “aboveand beyond” in the item rated.Comments are mandatory for this rating.VERY COMPETENT:The student on occasion demonstrates medical knowledge, clinical skills or professionalism at a level higher thanexpected for a fourth year student. In other words, the student on occasion, but not consistently, “goes the extra mile”and performs “above and beyond” in the item rated. The student should continue to strive for Exceptional ratings.Comments are mandatory for this rating.COMPETENT:The student demonstrates medical knowledge, clinical skills or professionalism at the level expected for a fourth yearstudent. The student should continue to strive for Very Competent and Exceptional ratings.Comments are mandatory for this rating.MARGINAL:The student demonstrates medical knowledge, clinical skills or professionalism slightly below the level expected for afourth year student. An item rated Marginal is an area of weakness that has been identified. The student will beexpected to work on this area of weakness and demonstrate improvement to the level expected for a fourth yearstudent.Comments are mandatory for this rating.UNSATISFACTORY:The student demonstrates medical knowledge, clinical skills or professionalism below the level expected for a fourthyear student. An item rated Unsatisfactory is an area of weakness that has been identified. Formal remediation maybe required.Comments are mandatory for this rating.Revised 7/18/11 3