Clinical Evaluation Form
For Northeast Ohio Medical University M4 Students

To be used for formative feedback only and sent to elective director. NEOMED does not process this form.
AY 2019-20

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Competency: Patient Care

Topics	Below Expectations	Meets Expectations	Exceeds Expectations	Unable to Assess
Gathers patient information through history, physical exam, and use of ancillary data	Gathers patient information through history, physical exam, and use of ancillary data, Below Expectations	Gathers patient information through history, physical exam, and use of ancillary data, Meets Expectations	Gathers patient information through history, physical exam, and use of ancillary data, Exceeds Expectations	Gathers patient information through history, physical exam, and use of ancillary data, Unable to Assess
Generates assessments and differential diagnoses.	Generates assessments and differential diagnoses., Below Expectations	Generates assessments and differential diagnoses., Meets Expectations	Generates assessments and differential diagnoses., Exceeds Expectations	Generates assessments and differential diagnoses., Unable to Assess
Develops and carries out patient management plans.	Develops and carries out patient management plans., Below Expectations	Develops and carries out patient management plans., Meets Expectations	Develops and carries out patient management plans., Exceeds Expectations	Develops and carries out patient management plans., Unable to Assess
Performs procedures essential for area of practice.	Performs procedures essential for area of practice., Below Expectations	Performs procedures essential for area of practice., Meets Expectations	Performs procedures essential for area of practice., Exceeds Expectations	Performs procedures essential for area of practice., Unable to Assess
Ensures continuity of care through transitions between providers or settings.	Ensures continuity of care through transitions between providers or settings., Below Expectations	Ensures continuity of care through transitions between providers or settings., Meets Expectations	Ensures continuity of care through transitions between providers or settings., Exceeds Expectations	Ensures continuity of care through transitions between providers or settings., Unable to Assess
Approaches tasks with a focus on patient safety.	Approaches tasks with a focus on patient safety., Below Expectations	Approaches tasks with a focus on patient safety., Meets Expectations	Approaches tasks with a focus on patient safety., Exceeds Expectations	Approaches tasks with a focus on patient safety., Unable to Assess
Provides appropriate role modeling.	Provides appropriate role modeling., Below Expectations	Provides appropriate role modeling., Meets Expectations	Provides appropriate role modeling., Exceeds Expectations	Provides appropriate role modeling., Unable to Assess
Performs supervisory responsibilities commensurate with role.	Performs supervisory responsibilities commensurate with role., Below Expectations	Performs supervisory responsibilities commensurate with role., Meets Expectations	Performs supervisory responsibilities commensurate with role., Exceeds Expectations	Performs supervisory responsibilities commensurate with role., Unable to Assess

Patient Care Comments:

Competency: Interpersonal and Communication Skills

Topics	Below Expectations	Meets Expectations	Exceeds Expectations	Unable to Assess
Communicates with patients and colleagues in a responsible manner.	Communicates with patients and colleagues in a responsible manner., Below Expectations	Communicates with patients and colleagues in a responsible manner., Meets Expectations	Communicates with patients and colleagues in a responsible manner., Exceeds Expectations	Communicates with patients and colleagues in a responsible manner., Unable to Assess
Works collaboratively with others as a member or leader of a team.	Works collaboratively with others as a member or leader of a team., Below Expectations	Works collaboratively with others as a member or leader of a team., Meets Expectations	Works collaboratively with others as a member or leader of a team., Exceeds Expectations	Works collaboratively with others as a member or leader of a team., Unable to Assess
Delivers oral presentations in an organized and efficient manner.	Delivers oral presentations in an organized and efficient manner., Below Expectations	Delivers oral presentations in an organized and efficient manner., Meets Expectations	Delivers oral presentations in an organized and efficient manner., Exceeds Expectations	Delivers oral presentations in an organized and efficient manner., Unable to Assess
Documents in an organized and efficient manner.	Documents in an organized and efficient manner., Below Expectations	Documents in an organized and efficient manner., Meets Expectations	Documents in an organized and efficient manner., Exceeds Expectations	Documents in an organized and efficient manner., Unable to Assess
Demonstrates sensitivity, honesty, and compassion in difficult conversations.	Demonstrates sensitivity, honesty, and compassion in difficult conversations., Below Expectations	Demonstrates sensitivity, honesty, and compassion in difficult conversations., Meets Expectations	Demonstrates sensitivity, honesty, and compassion in difficult conversations., Exceeds Expectations	Demonstrates sensitivity, honesty, and compassion in difficult conversations., Unable to Assess

I&CS Comments:

Competency: Knowledge for Practice

Topics	Needs Development	Progressing Appropriately	Exceptionally Advanced	Unable to Assess
Demonstrates an investigatory and analytic approach to clinical situations.	Demonstrates an investigatory and analytic approach to clinical situations., Needs Development	Demonstrates an investigatory and analytic approach to clinical situations., Progressing Appropriately	Demonstrates an investigatory and analytic approach to clinical situations., Exceptionally Advanced	Demonstrates an investigatory and analytic approach to clinical situations., Unable to Assess
Applies medical knowledge base to clinical situations.	Applies medical knowledge base to clinical situations., Needs Development	Applies medical knowledge base to clinical situations., Progressing Appropriately	Applies medical knowledge base to clinical situations., Exceptionally Advanced	Applies medical knowledge base to clinical situations., Unable to Assess

Knowledge for Practice Comments:

Competency: Practice-Based Learning and Improvement

Topics	Below Expectations	Meets Expectations	Exceeds Expectations	Unable to Assess
Identifies and performs learning activities that address one’s gaps in knowledge or skills.	Identifies and performs learning activities that address one’s gaps in knowledge or skills., Below Expectations	Identifies and performs learning activities that address one’s gaps in knowledge or skills., Meets Expectations	Identifies and performs learning activities that address one’s gaps in knowledge or skills., Exceeds Expectations	Identifies and performs learning activities that address one’s gaps in knowledge or skills., Unable to Assess
Participates in the education of patients and other health professionals.	Participates in the education of patients and other health professionals., Below Expectations	Participates in the education of patients and other health professionals., Meets Expectations	Participates in the education of patients and other health professionals., Exceeds Expectations	Participates in the education of patients and other health professionals., Unable to Assess
Incorporates feedback into daily practice.	Incorporates feedback into daily practice., Below Expectations	Incorporates feedback into daily practice., Meets Expectations	Incorporates feedback into daily practice., Exceeds Expectations	Incorporates feedback into daily practice., Unable to Assess
Locates, appraises, and assimilates evidence from scientific studies.	Locates, appraises, and assimilates evidence from scientific studies., Below Expectations	Locates, appraises, and assimilates evidence from scientific studies., Meets Expectations	Locates, appraises, and assimilates evidence from scientific studies., Exceeds Expectations	Locates, appraises, and assimilates evidence from scientific studies., Unable to Assess
	, Below Expectations	, Meets Expectations	, Exceeds Expectations	, Unable to Assess

PBL&I Comments:

Competency: Systems-Based Practice

Topics	Below Expectations	Meets Expectations	Unable to Assess
Works effectively in various health care delivery settings (e.g., inpatient, outpatient, interdisciplinary teams, etc.).	Works effectively in various health care delivery settings (e.g., inpatient, outpatient, interdisciplinary teams, etc.)., Below Expectations	Works effectively in various health care delivery settings (e.g., inpatient, outpatient, interdisciplinary teams, etc.)., Meets Expectations	Works effectively in various health care delivery settings (e.g., inpatient, outpatient, interdisciplinary teams, etc.)., Unable to Assess
Demonstrates knowledge of patient care coordination.	Demonstrates knowledge of patient care coordination., Below Expectations	Demonstrates knowledge of patient care coordination., Meets Expectations	Demonstrates knowledge of patient care coordination., Unable to Assess
Considers cost and risk-benefit in patient care.	Considers cost and risk-benefit in patient care., Below Expectations	Considers cost and risk-benefit in patient care., Meets Expectations	Considers cost and risk-benefit in patient care., Unable to Assess
Advocates for quality patient care and optimal patient care systems.	Advocates for quality patient care and optimal patient care systems., Below Expectations	Advocates for quality patient care and optimal patient care systems., Meets Expectations	Advocates for quality patient care and optimal patient care systems., Unable to Assess
	, Below Expectations	, Meets Expectations	, Unable to Assess

SBP Comments:

Competency: Professionalism

Topics	Below Expectations	Meets Expectations	Unable to Assess
Demonstrates compassion, integrity, and respect for others.	Demonstrates compassion, integrity, and respect for others., Below Expectations	Demonstrates compassion, integrity, and respect for others., Meets Expectations	Demonstrates compassion, integrity, and respect for others., Unable to Assess
Demonstrates responsiveness to patient needs that supersedes self-interest.	Demonstrates responsiveness to patient needs that supersedes self-interest., Below Expectations	Demonstrates responsiveness to patient needs that supersedes self-interest., Meets Expectations	Demonstrates responsiveness to patient needs that supersedes self-interest., Unable to Assess
Demonstrates respect for patient privacy and autonomy.	Demonstrates respect for patient privacy and autonomy., Below Expectations	Demonstrates respect for patient privacy and autonomy., Meets Expectations	Demonstrates respect for patient privacy and autonomy., Unable to Assess
Demonstrates sensitivity and responsiveness to diverse patient populations.	Demonstrates sensitivity and responsiveness to diverse patient populations., Below Expectations	Demonstrates sensitivity and responsiveness to diverse patient populations., Meets Expectations	Demonstrates sensitivity and responsiveness to diverse patient populations., Unable to Assess
Demonstrates trustworthiness and a commitment to ethical principles in all aspects of patient care.	Demonstrates trustworthiness and a commitment to ethical principles in all aspects of patient care., Below Expectations	Demonstrates trustworthiness and a commitment to ethical principles in all aspects of patient care., Meets Expectations	Demonstrates trustworthiness and a commitment to ethical principles in all aspects of patient care., Unable to Assess
Presents appropriate attire and demeanor.	Presents appropriate attire and demeanor., Below Expectations	Presents appropriate attire and demeanor., Meets Expectations	Presents appropriate attire and demeanor., Unable to Assess
Manages conflict between personal and professional responsibilities.	Manages conflict between personal and professional responsibilities., Below Expectations	Manages conflict between personal and professional responsibilities., Meets Expectations	Manages conflict between personal and professional responsibilities., Unable to Assess
Demonstrates leadership skills.	Demonstrates leadership skills., Below Expectations	Demonstrates leadership skills., Meets Expectations	Demonstrates leadership skills., Unable to Assess
Uses appropriate resources to deal with uncertainty.	Uses appropriate resources to deal with uncertainty., Below Expectations	Uses appropriate resources to deal with uncertainty., Meets Expectations	Uses appropriate resources to deal with uncertainty., Unable to Assess
	, Below Expectations	, Meets Expectations	, Unable to Assess

Professionalism Comments:

Block during which the student rotated:

Amount of time spent with the student:

Descriptions	Quantity	Unit
Topics		Hours	Days
Time:	Time:	Time:, Hours	Time:, Days

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Northeast Ohio Medical University