provencher - university of manitoba · 2020. 12. 7. · incorporates evidence-based medicine where...
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Max Rady College of Medicine
Department of Pediatrics & Child Health
PEDIATRIC UNDERGRADUATE MEDICAL EDUCATION CLINICAL CLERKSHIP
EVALUATION PACKAGE
Student Name: ____________________________
Please return to the Pediatric Undergraduate Medical Education Office (Children’s Hospital) CK239 - 840 Sherbook St., Winnipeg, MB, R3A 1S1
Provencher
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Max Rady College of Medicine Department of Pediatrics & Child Health
This booklet consists of the following evaluations:
• OH&P Evaluation
• Medical Student Admission Logbook • Ambulatory (OPD) Evaluations (ER/MTA/Derm/Gen Peds Clinics)
• Night Float Evaluation Package • Subspecialty Evaluation Package
Please return to the Pediatric Undergraduate Medical Education Office (Children’s Hospital) CK239 - 840 Sherbook St., Winnipeg, MB, R3A 1S1
file://///Ad.wrha.mb.ca/wrha/HSC/shared/CHP/CHP_PED_UNDERGRAD/Peds%20UGME/Clerkship/Clerkship%20Evaluation%20Forms/Original%20Word%20Versions/Peds%20Clerkship%20Evaluation%20Package.docfile://///Ad.wrha.mb.ca/wrha/HSC/shared/CHP/CHP_PED_UNDERGRAD/Peds%20UGME/Clerkship/Clerkship%20Evaluation%20Forms/Original%20Word%20Versions/Peds%20Clerkship%20Evaluation%20Package.doc
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Max Rady College of Medicine
Department of Pediatrics & Child Health
Observed History and Physical (OH&P) Examination Evaluation
The overall aim of the session is to provide the clinical clerk with an opportunity to be observed, completing a complete and appropriate pediatric history and physical examination.
All clerks must complete one observed history and physical examination during the outpatient portion of the Clerkship experience in Pediatrics. This will be a mandatory part of the rotation. The student will receive direct feedback from
his/her preceptor, as well as a written assessment form that will be part of the student’s documentation of time spent in Pediatrics. The goal of this session is to provide observation and informative feedback to the clerks so that they have an opportunity to learn from their experience and improve their skills.
This document outlines the responsibilities of the clerk and the mentors.
1. When should the history and physical examination take place? The observed history and physical examination should take place during any weekday during the 6-week pediatrics rotation. The Program Coordinator will work with the mentor to schedule the examination.
2. Who is the mentor? The mentor is the Clinical Ward Teacher or designate – Junior Attending, Pediatric Senior Resident, Pediatric
Chief Resident or Attending pediatrician. Clerks and their Attending Pediatrician should arrange an appropriate schedule so that all students on the service have a set time for the history and physical session. Ideally the clerks should have discussions with the Attending Pediatrician in the first days of the inpatient rotation.
3. Who should find a patient? The Pediatric Nurse Coordinator will be responsible for approaching a family for the examination. If possible, it is
best to avoid a patient who is already well known to the clerk.
4. How long should the examination take?
The clerk will be given 60 minutes to complete both the history and physical examination. The clerk is free to decide how best to divide up the time. The clerk is then provided with 10 minutes to summarize their thoughts and approximately 20-30 minutes is allocated for presentations of the case including differential diagnosis,
problem list as well as management plan as well as some discussion about the case. A further 20 minutes should be set aside for feedback. This should be considered protected time (total 2 hours).
5. Evaluations: 1. Preceptor Evaluation of medical clerk. The evaluation form should be reviewed between the mentor and the
clinical clerk at the time of the session. It is the clinical clerk’s responsibility to bring the form to the encounter. The clinical teacher will return the completed form to the Peds UGME Office (CK239 – Children’s Hospital). The form can also be downloaded from OPAL, the Peds UGME website or picked up from the Peds
UGME Office.
2. Student Evaluation of Preceptor. The student is to complete this evaluation as soon as possible following
his/her time with the mentor. The student can drop the completed form off at the Peds UGME Office (CK239 – Children’s Hospital) or submit it with the other evaluations at the Exit Interviews.
Please note: The major emphasis is on history and physical examination skills.
file://///Ad.wrha.mb.ca/wrha/HSC/shared/CHP/CHP_PED_UNDERGRAD/Peds%20UGME/Clerkship/Clerkship%20Evaluation%20Forms/Original%20Word%20Versions/Peds%20Clerkship%20Evaluation%20Package.docfile://///Ad.wrha.mb.ca/wrha/HSC/shared/CHP/CHP_PED_UNDERGRAD/Peds%20UGME/Clerkship/Clerkship%20Evaluation%20Forms/Original%20Word%20Versions/Peds%20Clerkship%20Evaluation%20Package.doc
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Max Rady College of Medicine
Department of Pediatrics & Child Health
Observed History & Physical (OH&P) Evaluation Student: Mentor:
Patient’s Age: _______ Sex: ________ Presenting Complaint:
*NI = Needs Improvement **Good = As expected for level of training
***NA = Not Applicable
**Evaluation of student should take into account level of training.
INTERVIEW PROCESS *NI **GOOD ***NA COMMENTS/EXAMPLES
1. INTRODUCTION
• Introduces & identifies self ______ _______ • Uses patient’s name ______ _______ • Reason for interview ______ _______
2. VOCABULARY
• Easily understood ______ _______ • Avoids medical jargon ______ _______
• Clarifies historian’s terms ______ _______ 3. TECHNIQUE
• Ease of questioning ______ _______
• Mixes open and closed questions ______ _______ • Asks one question at a time ______ _______ • Waits for answer ______ _______ • Avoids repetition ______ _______
4. INTERACTION WITH PATIENT
• Puts patient at ease ______ _______
• Establishes eye contact ______ _______ • Receptive to nuances ______ _______ • Establishes control of interview ______ _______ • Answers questions appropriately ______ _______
5. INTERACTION WITH PARENT
• Puts parent at ease ______ _______ • Establishes eye contact ______ _______
• Receptive to nuances ______ _______ • Establishes control of interview ______ _______ • Answers questions appropriately ______ _______
file://///Ad.wrha.mb.ca/wrha/HSC/shared/CHP/CHP_PED_UNDERGRAD/Peds%20UGME/Clerkship/Clerkship%20Evaluation%20Forms/Original%20Word%20Versions/Peds%20Clerkship%20Evaluation%20Package.docfile://///Ad.wrha.mb.ca/wrha/HSC/shared/CHP/CHP_PED_UNDERGRAD/Peds%20UGME/Clerkship/Clerkship%20Evaluation%20Forms/Original%20Word%20Versions/Peds%20Clerkship%20Evaluation%20Package.doc
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**NI **GOOD ***NA COMMENTS/EXAMPLE HISTORY CONTENT 1. PROBLEM ORIENTATION
• Deals adequately with present illness Including impact on activities of daily living ______ _______
• Deals with secondary problems including physical limitations and supports ______ _______
• Organized and rational approach ______ _______ • Emphasizes major complaints ______ _______
• Flexibility ______ _______ • Avoids unnecessary detail ______ _______
2. COMPREHENSIVENESS Full functional enquiry (systems review) - Pertinent:
• Medication history ______ _______ • Allergy history ______ _______ • Immunization history ______ _______
• Developmental history ______ _______ • Family history ______ _______ • Social history (include sexual if adolescent.) ______ _______ • Obstetrical perinatal history ______ _______
• Nutritional history ______ _______
PHYSICAL EXAMINATION 1. PROBLEM ORIENTATION
• Focused on problems elicited in history ______ _______
• Examines relevant areas thoroughly ______ _______ • Screening exam of other systems ______ _______
(as appropriate for time and situation) 2. OPPORTUNISTIC APPROACH
• Obtains best information without upsetting the child ______ _______ _
• Shows flexible approach ______ _______
3. COMPREHENSIVENESS Appropriate for time, situation and patient/parent comfort, including exam of the following:
• Head and Neck ______ _______ • Respiratory ______ _______
• Cardiovascular ______ _______ • Gastrointestinal ______ _______ • Musculoskeletal ______ _______ • Lymph ______ _______
• Central Nervous System ______ _______ • Skin ______ _______ • Genitourinary ______ _______
file://///Ad.wrha.mb.ca/wrha/HSC/shared/CHP/CHP_PED_UNDERGRAD/Peds%20UGME/Clerkship/Clerkship%20Evaluation%20Forms/Original%20Word%20Versions/Peds%20Clerkship%20Evaluation%20Package.docfile://///Ad.wrha.mb.ca/wrha/HSC/shared/CHP/CHP_PED_UNDERGRAD/Peds%20UGME/Clerkship/Clerkship%20Evaluation%20Forms/Original%20Word%20Versions/Peds%20Clerkship%20Evaluation%20Package.doc
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*NI **GOOD ***NA COMMENTS/EXAMPLES 4. TECHNIQUE
• Prior explanation ______ _______ • Respect for patient’s modesty ______ _______
• Appropriate draping ______ _______ • Appropriate positioning of patient ______ _______ • Able to elicit physical signs ______ _______ • Keeps patient comfortable (interacts) ______ _______ • Washes hands before and after ______ _______
• Avoids persisting with distressing exam ______ _______ DISCUSSION
• Initial problem list ______ _______ • DDX of at least one problem ______ _______ • Initial management plan ______ _______
SUMMARY
1. STRENGTHS - (Be specific, using examples from the encounter)
2. ASPECTS REQUIRING FURTHER WORK - (Be specific, using examples from the encounter)
OVERALL ASSESSMENT
Meets Expectations Needs Improvement Repeat Session Recommended
Observers Signature: Date: ___________________________ Time: __________ Student’s Signature: Date: ___________________________ Time: __________
Please return to the Pediatric Undergraduate Medical Education Office (Children’s Hospital) CK239 - 840 Sherbook St., Winnipeg, MB, R3A 1S1
file://///Ad.wrha.mb.ca/wrha/HSC/shared/CHP/CHP_PED_UNDERGRAD/Peds%20UGME/Clerkship/Clerkship%20Evaluation%20Forms/Original%20Word%20Versions/Peds%20Clerkship%20Evaluation%20Package.docfile://///Ad.wrha.mb.ca/wrha/HSC/shared/CHP/CHP_PED_UNDERGRAD/Peds%20UGME/Clerkship/Clerkship%20Evaluation%20Forms/Original%20Word%20Versions/Peds%20Clerkship%20Evaluation%20Package.doc
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Max Rady College of Medicine
Department of Pediatrics & Child Health
Observed History & Physical – Evaluation of Preceptor
Date of Encounter: Preceptor:
Please evaluate this session by marking the appropriate boxes below.
Not
Applicable 0
Did Not
Occur 1
Below
Expectations 2
Met
Expectations 3
Above
Expectations 4
Establishes a stimulating learning environment that is non-threatening
Clearly specifies what I am expected to
know and adjusts teaching to my needs
Allows me autonomy appropriate to my
level of training
Organizes time for both teaching and
caregiving
Gives clear explanations and
incorporates evidence-based medicine where appropriate
Coaches me on my clinical skills
Gave me constructive feedback to
promote further learning
Overall quality of this preceptor
Comments:
Please return to the Pediatric Undergraduate Medical Education Office (Children’s Hospital)
CK239 - 840 Sherbook St., Winnipeg, MB, R3A 1S1
file://///Ad.wrha.mb.ca/wrha/HSC/shared/CHP/CHP_PED_UNDERGRAD/Peds%20UGME/Clerkship/Clerkship%20Evaluation%20Forms/Original%20Word%20Versions/Peds%20Clerkship%20Evaluation%20Package.docfile://///Ad.wrha.mb.ca/wrha/HSC/shared/CHP/CHP_PED_UNDERGRAD/Peds%20UGME/Clerkship/Clerkship%20Evaluation%20Forms/Original%20Word%20Versions/Peds%20Clerkship%20Evaluation%20Package.doc
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Max Rady College of Medicine Department of Pediatrics & Child Health
Medical Student Admission Logbook
(Students must log a minimum of 4 admissions)
Name of Medical Student:
Service/Ward: Oak Elm Pine
Date of Admission Signature of Resident (print name)
Please return to the Pediatric Undergraduate Medical Education Office (Children’s Hospital)
CK239 - 840 Sherbook St., Winnipeg, MB, R3A 1S1
file://///Ad.wrha.mb.ca/wrha/HSC/shared/CHP/CHP_PED_UNDERGRAD/Peds%20UGME/Clerkship/Clerkship%20Evaluation%20Forms/Original%20Word%20Versions/Peds%20Clerkship%20Evaluation%20Package.docfile://///Ad.wrha.mb.ca/wrha/HSC/shared/CHP/CHP_PED_UNDERGRAD/Peds%20UGME/Clerkship/Clerkship%20Evaluation%20Forms/Original%20Word%20Versions/Peds%20Clerkship%20Evaluation%20Package.doc
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Max Rady College of Medicine
Department of Pediatrics & Child Health
PEDIATRIC UNDERGRADUATE MEDICAL EDUCATION CLINICAL CLERKSHIP
PRECEPTOR EVALUATIONS OF MEDICAL CLERK
AMBULATORY (OPD) ROTATION
Student Name: ____________________________
Please return to the Pediatric Undergraduate Medical Education Office (Children’s Hospital) CK239 - 840 Sherbook St., Winnipeg, MB, R3A 1S1
Provencher
file://///Ad.wrha.mb.ca/wrha/HSC/shared/CHP/CHP_PED_UNDERGRAD/Peds%20UGME/Clerkship/Clerkship%20Evaluation%20Forms/Original%20Word%20Versions/Peds%20Clerkship%20Evaluation%20Package.docfile://///Ad.wrha.mb.ca/wrha/HSC/shared/CHP/CHP_PED_UNDERGRAD/Peds%20UGME/Clerkship/Clerkship%20Evaluation%20Forms/Original%20Word%20Versions/Peds%20Clerkship%20Evaluation%20Package.doc
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Max Rady College of Medicine Department of Pediatrics & Child Health
Learner Background Form
Name: Preceptor:
School, Level of Training: Dates of Rotation:
Personal Information (anything that will help the preceptor and staff get to know you a bit):
Previous Clinical Experience - Rotations Completed:
Family Medicine OB/GYN Psychiatry Surgery Internal Medicine MSR Other _______________
Other clinical experiences you have had:
Aspects of medicine you have particularly enjoyed or disliked so far, and why :
Career interests at this point:
file://///Ad.wrha.mb.ca/wrha/HSC/shared/CHP/CHP_PED_UNDERGRAD/Peds%20UGME/Clerkship/Clerkship%20Evaluation%20Forms/Original%20Word%20Versions/Peds%20Clerkship%20Evaluation%20Package.docfile://///Ad.wrha.mb.ca/wrha/HSC/shared/CHP/CHP_PED_UNDERGRAD/Peds%20UGME/Clerkship/Clerkship%20Evaluation%20Forms/Original%20Word%20Versions/Peds%20Clerkship%20Evaluation%20Package.doc
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Special Requests for this rotation:
Specific topics, skills or problems you hope to address during this rotation and how your interests might be addressed.
Areas in which you would like specific feedback during the rotation:
Rotation Objectives
This form is to be completed in the first few days of the rotation and then referred back to during
mid-rotation and end-rotations.
Learner: Preceptor:
Level of Training: Dates of Rotation:
The learner and preceptor agree to the following specific objectives for this rotation (regarding learner’s knowledge, skills, or attitudes; specific procedures, type exams, clinical problems, psychosocial issues; etc.) Strategies for meeting these objectives include:
Please return to the Pediatric Undergraduate Medical Education Office (Children’s Hospital) CK239 - 840 Sherbook St., Winnipeg, MB, R3A 1S1
file://///Ad.wrha.mb.ca/wrha/HSC/shared/CHP/CHP_PED_UNDERGRAD/Peds%20UGME/Clerkship/Clerkship%20Evaluation%20Forms/Original%20Word%20Versions/Peds%20Clerkship%20Evaluation%20Package.docfile://///Ad.wrha.mb.ca/wrha/HSC/shared/CHP/CHP_PED_UNDERGRAD/Peds%20UGME/Clerkship/Clerkship%20Evaluation%20Forms/Original%20Word%20Versions/Peds%20Clerkship%20Evaluation%20Package.doc
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CHILDREN’S EMERGENCY – SESSION #1
Can Meds Role: Manager/Health Advocate/ Scholar Date: Student (print name) Preceptor: Attending Resident (print name)
Signatures:
Medical Student Self Evaluation
What did I do well today?
After today, what do I need to work on?
Attending Evaluation
Do you agree with the self-evaluation?
What was the medical student’s strength today?
Identify one issue or skill for deeper/further learning:
CanMEDS role for today to be specifically assessed: MANAGER/ HEALTH ADVOCATE / SCHOLAR
1=Unsatisfactory; 2=Below Expectations; 3=Meets Expectations;
4=Exceeds Expectations; 5=Outstanding; NA= Not Assessed 1 2 3 4 5 NA
Time Management (organized, efficient, punctual) (Minor)
Health Promotion Strategies (Knows disease prevention, health promotion) (Minor)
Determinants of Health (understands social determinants affecting health) (Minor)
Self-directed learning (self-initiative, relevant reading) (Major)
Knowledge and application of evidence-based medicine (Minor)
Contributions to learning activities (enthusiasm, engagement) (Minor)
Oral presentations organization and relevance (Minor)
Please return to the Pediatric Undergraduate Medical Education Office (Children’s Hospital)
CK239 - 840 Sherbook St., Winnipeg, MB, R3A 1S1
Yes
No (If No, why?):
file://///Ad.wrha.mb.ca/wrha/HSC/shared/CHP/CHP_PED_UNDERGRAD/Peds%20UGME/Clerkship/Clerkship%20Evaluation%20Forms/Original%20Word%20Versions/Peds%20Clerkship%20Evaluation%20Package.docfile://///Ad.wrha.mb.ca/wrha/HSC/shared/CHP/CHP_PED_UNDERGRAD/Peds%20UGME/Clerkship/Clerkship%20Evaluation%20Forms/Original%20Word%20Versions/Peds%20Clerkship%20Evaluation%20Package.doc
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CHILDREN’S EMERGENCY – SESSION #2 Can Meds Role: Medical Expert/Communicator/Collaborator
Date: Student (print name) Preceptor: Attending Resident (print name)
Signatures:
Medical Student Self Evaluation
What did I do well today?
After today, what do I need to work on?
Attending Evaluation
Do you agree with the self-evaluation?
What was the medical student’s strength today?
Identify one issue or skill for deeper/further learning:
CanMEDS role for today to be specifically assessed: MEDICAL EXPERT
1=Unsatisfactory; 2=Below Expectations; 3=Meets Expectations;
4=Exceeds Expectations; 5=Outstanding; NA= Not Assessed 1 2 3 4 5 NA
History Taking Skills (Major)
Physical Exam Skills (Major)
Diagnostic Investigations (Major)
Differential Diagnosis formulation skills (Major)
Management plans (minor)
Discipline-specific procedural skills (minor)
CanMEDS role for today to be specifically assessed: COMMUNICATOR and COLLABORATOR
1=Unsatisfactory; 2=Below Expectations; 3=Meets Expectations;
4=Exceeds Expectations; 5=Outstanding; NA= Not Assessed
1 2 3 4 5 NA
Communication with patients (Major)
Communication with families (Major)
Written records (Major)
Communication with other health care professions (Major)
Please return to the Pediatric Undergraduate Medical Education Office (Children’s Hospital) CK239 - 840 Sherbook St., Winnipeg, MB, R3A 1S1
Yes
No (If No, why?):
file://///Ad.wrha.mb.ca/wrha/HSC/shared/CHP/CHP_PED_UNDERGRAD/Peds%20UGME/Clerkship/Clerkship%20Evaluation%20Forms/Original%20Word%20Versions/Peds%20Clerkship%20Evaluation%20Package.docfile://///Ad.wrha.mb.ca/wrha/HSC/shared/CHP/CHP_PED_UNDERGRAD/Peds%20UGME/Clerkship/Clerkship%20Evaluation%20Forms/Original%20Word%20Versions/Peds%20Clerkship%20Evaluation%20Package.doc
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MINOR TREATMENT AREA (FAST TRACK) – SESSION #1 Can Meds Role: Professional
Date: Student (print name) Preceptor: Attending Resident (print name)
Signatures:
Medical Student Self Evaluation
What did I do well today?
After today, what do I need to work on?
Attending Evaluation
Do you agree with the self-evaluation?
What was the medical student’s strength today?
Identify one issue or skill for deeper/further learning:
CanMEDS role for today to be specifically assessed: PROFESSIONAL
1=Unsatisfactory; 2=Below Expectations; 3=Meets Expectations;
4=Exceeds Expectations; 5=Outstanding; NA= Not Assessed
1 2 3 4 5 NA
Integrity/Altruism (Honest, respectful, role model) (Major)
Responsibility and conscientiousness (prepared, engaged, model behaviour) (Major)
Self-assessment (seeks and responds well to feedback) (Minor)
Personal Demeanor (professional appearance, hygiene and conduct) (Minor)
Please return to the Pediatric Undergraduate Medical Education Office (Children’s Hospital)
CK239 - 840 Sherbook St., Winnipeg, MB, R3A 1S1
Yes
No (If No, why?):
file://///Ad.wrha.mb.ca/wrha/HSC/shared/CHP/CHP_PED_UNDERGRAD/Peds%20UGME/Clerkship/Clerkship%20Evaluation%20Forms/Original%20Word%20Versions/Peds%20Clerkship%20Evaluation%20Package.docfile://///Ad.wrha.mb.ca/wrha/HSC/shared/CHP/CHP_PED_UNDERGRAD/Peds%20UGME/Clerkship/Clerkship%20Evaluation%20Forms/Original%20Word%20Versions/Peds%20Clerkship%20Evaluation%20Package.doc
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MINOR TREATMENT AREA (FAST TRACK) – SESSION #2 Can Meds Role: Medical Expert/Communicator/Collaborator
Date: Student (print name) Preceptor: Attending Resident (print name)
Signatures:
Medical Student Self Evaluation
What did I do well today?
After today, what do I need to work on?
Attending Evaluation
Do you agree with the self-evaluation?
What was the medical student’s strength today?
Identify one issue or skill for deeper/further learning:
CanMEDS role for today to be specifically assessed: MEDICAL EXPERT
1=Unsatisfactory; 2=Below Expectations; 3=Meets Expectations;
4=Exceeds Expectations; 5=Outstanding; NA= Not Assessed
1 2 3 4 5 NA
History Taking Skills (Major)
Physical Exam Skills (Major)
Diagnostic Investigations (Major)
Differential Diagnosis formulation skills (Major)
Management plans (minor)
Discipline-specific procedural skills (minor)
CanMEDS role for today to be specifically assessed: COMMUNICATOR and COLLABORATOR
1=Unsatisfactory; 2=Below Expectations; 3=Meets Expectations;
4=Exceeds Expectations; 5=Outstanding; NA= Not Assessed 1 2 3 4 5 NA
Communication with patients (Major)
Communication with families (Major)
Written records (Major)
Communication with other health care professions (Major)
Please return to the Pediatric Undergraduate Medical Education Office (Children’s Hospital) CK239 - 840 Sherbook St., Winnipeg, MB, R3A 1S1
Yes
No (If No, why?):
file://///Ad.wrha.mb.ca/wrha/HSC/shared/CHP/CHP_PED_UNDERGRAD/Peds%20UGME/Clerkship/Clerkship%20Evaluation%20Forms/Original%20Word%20Versions/Peds%20Clerkship%20Evaluation%20Package.docfile://///Ad.wrha.mb.ca/wrha/HSC/shared/CHP/CHP_PED_UNDERGRAD/Peds%20UGME/Clerkship/Clerkship%20Evaluation%20Forms/Original%20Word%20Versions/Peds%20Clerkship%20Evaluation%20Package.doc
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DERMATOLOGY or EXTRA CHILDREN’S EMERGENCY Can Meds Role: Professional
Date: Student (print name) Preceptor: Attending Resident (print name)
Signatures:
Medical Student Self Evaluation
What did I do well today?
After today, what do I need to work on?
Attending Evaluation
Do you agree with the self-evaluation?
What was the medical student’s strength today?
Identify one issue or skill for deeper/further learning:
CanMEDS role for today to be specifically assessed: PROFESSIONAL
1=Unsatisfactory; 2=Below Expectations; 3=Meets Expectations;
4=Exceeds Expectations; 5=Outstanding; NA= Not Assessed
1 2 3 4 5 NA
Integrity/Altruism (Honest, respectful, role model) (Major)
Responsibility and conscientiousness (prepared, engaged, model behaviour) (Major)
Self-assessment (seeks and responds well to feedback) (Minor)
Personal Demeanor (professional appearance, hygiene and conduct) (Minor)
Please return to the Pediatric Undergraduate Medical Education Office (Children’s Hospital)
CK239 - 840 Sherbook St., Winnipeg, MB, R3A 1S1
Yes
No (If No, why?):
file://///Ad.wrha.mb.ca/wrha/HSC/shared/CHP/CHP_PED_UNDERGRAD/Peds%20UGME/Clerkship/Clerkship%20Evaluation%20Forms/Original%20Word%20Versions/Peds%20Clerkship%20Evaluation%20Package.docfile://///Ad.wrha.mb.ca/wrha/HSC/shared/CHP/CHP_PED_UNDERGRAD/Peds%20UGME/Clerkship/Clerkship%20Evaluation%20Forms/Original%20Word%20Versions/Peds%20Clerkship%20Evaluation%20Package.doc
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\\Ad.wrha.mb.ca\wrha\HSC\shared\CHP\CHP_PED_UNDERGRAD\Peds UGME\Clerkship\Clerkship Evaluation Forms\Original Word Versions\Peds Clerkship Evaluation Package.doc
17
GENERAL PEDIATRIC CLINICS – SESSION #1 Can Meds Role – Medical Expert/Communicator/Collaborator
Date: Student (print name) Preceptor: Attending Resident (print name)
Signatures:
Medical Student Self Evaluation
What did I do well today?
After today, what do I need to work on?
Attending Evaluation
Do you agree with the self-evaluation?
What was the medical student’s strength today?
Identify one issue or skill for deeper/further learning:
CanMEDS role for today to be specifically assessed: MEDICAL EXPERT
1=Unsatisfactory; 2=Below Expectations; 3=Meets Expectations;
4=Exceeds Expectations; 5=Outstanding; NA= Not Assessed
1 2 3 4 5 NA
History Taking Skills (Major)
Physical Exam Skills (Major)
Diagnostic Investigations (Major)
Differential Diagnosis formulation skills (Major)
Management plans (minor)
Discipline-specific procedural skills (minor)
CanMEDS role for today to be specifically assessed: COMMUNICATOR and COLLABORATOR
1=Unsatisfactory; 2=Below Expectations; 3=Meets Expectations;
4=Exceeds Expectations; 5=Outstanding; NA= Not Assessed 1 2 3 4 5 NA
Communication with patients (Major)
Communication with families (Major)
Written records (Major)
Communication with other health care professions (Major)
Please return to the Pediatric Undergraduate Medical Education Office (Children’s Hospital) CK239 - 840 Sherbook St., Winnipeg, MB, R3A 1S1
Yes
No (If No, why?):
file://///Ad.wrha.mb.ca/wrha/HSC/shared/CHP/CHP_PED_UNDERGRAD/Peds%20UGME/Clerkship/Clerkship%20Evaluation%20Forms/Original%20Word%20Versions/Peds%20Clerkship%20Evaluation%20Package.docfile://///Ad.wrha.mb.ca/wrha/HSC/shared/CHP/CHP_PED_UNDERGRAD/Peds%20UGME/Clerkship/Clerkship%20Evaluation%20Forms/Original%20Word%20Versions/Peds%20Clerkship%20Evaluation%20Package.doc
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\\Ad.wrha.mb.ca\wrha\HSC\shared\CHP\CHP_PED_UNDERGRAD\Peds UGME\Clerkship\Clerkship Evaluation Forms\Original Word Versions\Peds Clerkship Evaluation Package.doc
18
GENERAL PEDIATRIC CLINICS: Session #2 Can Meds Role: Manager, Health Advocate, Scholar
Date: Student (print name) Preceptor: Attending Resident (print name)
Signatures:
Medical Student Self Evaluation
What did I do well today?
After today, what do I need to work on?
Attending Evaluation
Do you agree with the self-evaluation?
What was the medical student’s strength today?
Identify one issue or skill for deeper/further learning:
CanMEDS role for today to be specifically assessed: MANAGER, HEALTH ADVOCATE, SCHOLAR
1=Unsatisfactory; 2=Below Expectations; 3=Meets Expectations;
4=Exceeds Expectations; 5=Outstanding; NA= Not Assessed
1 2 3 4 5 NA
Time Management (organized, efficient, punctual) (Minor)
Health Promotion Strategies (Knows disease prevention, health promotion) (Minor)
Determinants of Health (understands social determinants affecting health) (Minor)
Self-directed learning (self-initiative, relevant reading) (Major)
Knowledge and application of evidence-based medicine (Minor)
Contributions to learning activities (enthusiasm, engagement) (Minor)
Oral presentations organization and relevance (Minor)
Please return to the Pediatric Undergraduate Medical Education Office (Children’s Hospital)
CK239 - 840 Sherbook St., Winnipeg, MB, R3A 1S1
Yes
No (If No, why?):
file://///Ad.wrha.mb.ca/wrha/HSC/shared/CHP/CHP_PED_UNDERGRAD/Peds%20UGME/Clerkship/Clerkship%20Evaluation%20Forms/Original%20Word%20Versions/Peds%20Clerkship%20Evaluation%20Package.docfile://///Ad.wrha.mb.ca/wrha/HSC/shared/CHP/CHP_PED_UNDERGRAD/Peds%20UGME/Clerkship/Clerkship%20Evaluation%20Forms/Original%20Word%20Versions/Peds%20Clerkship%20Evaluation%20Package.doc
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\\Ad.wrha.mb.ca\wrha\HSC\shared\CHP\CHP_PED_UNDERGRAD\Peds UGME\Clerkship\Clerkship Evaluation Forms\Original Word Versions\Peds Clerkship Evaluation Package.doc
19
GENERAL PEDIATRIC CLINICS – SESSION #3 Can Meds Role: Professional
Date: Student (print name) Preceptor: Attending Resident (print name)
Signatures:
Medical Student Self Evaluation
What did I do well today?
After today, what do I need to work on?
Attending Evaluation
Do you agree with the self-evaluation?
What was the medical student’s strength today?
Identify one issue or skill for deeper/further learning:
CanMEDS role for today to be specifically assessed: PROFESSIONAL
1=Unsatisfactory; 2=Below Expectations; 3=Meets Expectations;
4=Exceeds Expectations; 5=Outstanding; NA= Not Assessed
1 2 3 4 5 NA
Integrity/Altruism (Honest, respectful, role model) (Major)
Responsibility and conscientiousness (prepared, engaged, model behaviour) (Major)
Self-assessment (seeks and responds well to feedback) (Minor)
Personal Demeanor (professional appearance, hygiene and conduct) (Minor)
Please return to the Pediatric Undergraduate Medical Education Office (Children’s Hospital)
CK239 - 840 Sherbook St., Winnipeg, MB, R3A 1S1
Yes
No (If No, why?):
file://///Ad.wrha.mb.ca/wrha/HSC/shared/CHP/CHP_PED_UNDERGRAD/Peds%20UGME/Clerkship/Clerkship%20Evaluation%20Forms/Original%20Word%20Versions/Peds%20Clerkship%20Evaluation%20Package.docfile://///Ad.wrha.mb.ca/wrha/HSC/shared/CHP/CHP_PED_UNDERGRAD/Peds%20UGME/Clerkship/Clerkship%20Evaluation%20Forms/Original%20Word%20Versions/Peds%20Clerkship%20Evaluation%20Package.doc
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\\Ad.wrha.mb.ca\wrha\HSC\shared\CHP\CHP_PED_UNDERGRAD\Peds UGME\Clerkship\Clerkship Evaluation Forms\Original Word Versions\Peds Clerkship Evaluation Package.doc
20
Max Rady College of Medicine
Department of Pediatrics & Child Health
PEDIATRIC UNDERGRADUATE MEDICAL EDUCATION
CLINICAL CLERKSHIP
PRECEPTOR EVALUATIONS OF MEDICAL CLERK NIGHT FLOAT ROTATION
Student Name: ____________________________
Please return to the Pediatric Undergraduate Medical Education Office (Children’s Hospital) CK239 - 840 Sherbook St., Winnipeg, MB, R3A 1S1
file://///Ad.wrha.mb.ca/wrha/HSC/shared/CHP/CHP_PED_UNDERGRAD/Peds%20UGME/Clerkship/Clerkship%20Evaluation%20Forms/Original%20Word%20Versions/Peds%20Clerkship%20Evaluation%20Package.docfile://///Ad.wrha.mb.ca/wrha/HSC/shared/CHP/CHP_PED_UNDERGRAD/Peds%20UGME/Clerkship/Clerkship%20Evaluation%20Forms/Original%20Word%20Versions/Peds%20Clerkship%20Evaluation%20Package.doc
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\\Ad.wrha.mb.ca\wrha\HSC\shared\CHP\CHP_PED_UNDERGRAD\Peds UGME\Clerkship\Clerkship Evaluation Forms\Original Word Versions\Peds Clerkship Evaluation Package.doc
21
NIGHT FLOAT EVALUATION PACKAGE – CALL #1
Date: Student (print name) Preceptor: Attending Resident (print name)
Signatures:
Medical Student Self Evaluation
What did I do well today?
After today, what do I need to work on?
Attending Evaluation
Do you agree with the self-evaluation?
What was the medical student’s strength today?
Identify one issue or skill for deeper/further learning:
1=Unsatisfactory; 2=Below Expectations; 3=Meets Expectations;
4=Exceeds Expectations; 5=Outstanding; NA= Not Assessed
1 2 3 4 5 NA
Communication Skills
History
Physical Examination
Discussion and presentation
Time Management
Please return to the Pediatric Undergraduate Medical Education Office (Children’s Hospital)
CK239 - 840 Sherbook St., Winnipeg, MB, R3A 1S1
Yes
No (If No, why?):
file://///Ad.wrha.mb.ca/wrha/HSC/shared/CHP/CHP_PED_UNDERGRAD/Peds%20UGME/Clerkship/Clerkship%20Evaluation%20Forms/Original%20Word%20Versions/Peds%20Clerkship%20Evaluation%20Package.docfile://///Ad.wrha.mb.ca/wrha/HSC/shared/CHP/CHP_PED_UNDERGRAD/Peds%20UGME/Clerkship/Clerkship%20Evaluation%20Forms/Original%20Word%20Versions/Peds%20Clerkship%20Evaluation%20Package.doc
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\\Ad.wrha.mb.ca\wrha\HSC\shared\CHP\CHP_PED_UNDERGRAD\Peds UGME\Clerkship\Clerkship Evaluation Forms\Original Word Versions\Peds Clerkship Evaluation Package.doc
22
NIGHT FLOAT EVALUATION PACKAGE – CALL #2
Date: Student (print name) Preceptor: Attending Resident (print name)
Signatures:
Medical Student Self Evaluation
What did I do well today?
After today, what do I need to work on?
Attending Evaluation
Do you agree with the self-evaluation?
What was the medical student’s strength today?
Identify one issue or skill for deeper/further learning:
1=Unsatisfactory; 2=Below Expectations; 3=Meets Expectations;
4=Exceeds Expectations; 5=Outstanding; NA= Not Assessed
1 2 3 4 5 NA
Communication Skills
History
Physical Examination
Discussion and presentation
Time Management
Please return to the Pediatric Undergraduate Medical Education Office (Children’s Hospital)
CK239 - 840 Sherbook St., Winnipeg, MB, R3A 1S1
Yes
No (If No, why?):
file://///Ad.wrha.mb.ca/wrha/HSC/shared/CHP/CHP_PED_UNDERGRAD/Peds%20UGME/Clerkship/Clerkship%20Evaluation%20Forms/Original%20Word%20Versions/Peds%20Clerkship%20Evaluation%20Package.docfile://///Ad.wrha.mb.ca/wrha/HSC/shared/CHP/CHP_PED_UNDERGRAD/Peds%20UGME/Clerkship/Clerkship%20Evaluation%20Forms/Original%20Word%20Versions/Peds%20Clerkship%20Evaluation%20Package.doc
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\\Ad.wrha.mb.ca\wrha\HSC\shared\CHP\CHP_PED_UNDERGRAD\Peds UGME\Clerkship\Clerkship Evaluation Forms\Original Word Versions\Peds Clerkship Evaluation Package.doc
23
NIGHT FLOAT EVALUATION PACKAGE – CALL #3
Date: Student (print name) Preceptor: Attending Resident (print name)
Signatures:
Medical Student Self Evaluation
What did I do well today?
After today, what do I need to work on?
Attending Evaluation
Do you agree with the self-evaluation?
What was the medical student’s strength today?
Identify one issue or skill for deeper/further learning:
1=Unsatisfactory; 2=Below Expectations; 3=Meets Expectations;
4=Exceeds Expectations; 5=Outstanding; NA= Not Assessed
1 2 3 4 5 NA
Communication Skills
History
Physical Examination
Discussion and presentation
Time Management
Please return to the Pediatric Undergraduate Medical Education Office (Children’s Hospital)
CK239 - 840 Sherbook St., Winnipeg, MB, R3A 1S1
Yes
No (If No, why?):
file://///Ad.wrha.mb.ca/wrha/HSC/shared/CHP/CHP_PED_UNDERGRAD/Peds%20UGME/Clerkship/Clerkship%20Evaluation%20Forms/Original%20Word%20Versions/Peds%20Clerkship%20Evaluation%20Package.docfile://///Ad.wrha.mb.ca/wrha/HSC/shared/CHP/CHP_PED_UNDERGRAD/Peds%20UGME/Clerkship/Clerkship%20Evaluation%20Forms/Original%20Word%20Versions/Peds%20Clerkship%20Evaluation%20Package.doc
-
\\Ad.wrha.mb.ca\wrha\HSC\shared\CHP\CHP_PED_UNDERGRAD\Peds UGME\Clerkship\Clerkship Evaluation Forms\Original Word Versions\Peds Clerkship Evaluation Package.doc
24
Max Rady College of Medicine
Department of Pediatrics & Child Health
PEDIATRIC UNDERGRADUATE MEDICAL EDUCATION CLINICAL CLERKSHIP
PRECEPTOR EVALUATIONS OF MEDICAL CLERK
SUBSPECIALTY ROTATION
Student Name: ____________________________
Please return to the Pediatric Undergraduate Medical Education Office (Children’s Hospital) CK239 - 840 Sherbook St., Winnipeg, MB, R3A 1S1
file://///Ad.wrha.mb.ca/wrha/HSC/shared/CHP/CHP_PED_UNDERGRAD/Peds%20UGME/Clerkship/Clerkship%20Evaluation%20Forms/Original%20Word%20Versions/Peds%20Clerkship%20Evaluation%20Package.docfile://///Ad.wrha.mb.ca/wrha/HSC/shared/CHP/CHP_PED_UNDERGRAD/Peds%20UGME/Clerkship/Clerkship%20Evaluation%20Forms/Original%20Word%20Versions/Peds%20Clerkship%20Evaluation%20Package.doc
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\\Ad.wrha.mb.ca\wrha\HSC\shared\CHP\CHP_PED_UNDERGRAD\Peds UGME\Clerkship\Clerkship Evaluation Forms\Original Word Versions\Peds Clerkship Evaluation Package.doc
25
SUBSPECIALTY – SESSION #1 Can Meds Role: Medical Expert/Communicator/Collaborator
Date: Student (print name) Preceptor: Attending Resident (print name) I supervised the student (circle one): AM / PM
Signatures:
Medical Student Self Evaluation
What did I do well today?
After today, what do I need to work on?
Attending Evaluation
Do you agree with the self-evaluation?
What was the medical student’s strength today?
Identify one issue or skill for deeper/further learning:
CanMEDS role for today to be specifically assessed: MEDICAL EXPERT
1=Unsatisfactory; 2=Below Expectations; 3=Meets Expectations;
4=Exceeds Expectations; 5=Outstanding; NA= Not Assessed
1 2 3 4 5 NA
History Taking Skills (Major)
Physical Exam Skills (Major)
Diagnostic Investigations (Major)
Differential Diagnosis formulation skills (Major)
Management plans (minor)
Discipline-specific procedural skills (minor)
CanMEDS role for today to be specifically assessed: COMMUNICATOR and COLLABORATOR
1=Unsatisfactory; 2=Below Expectations; 3=Meets Expectations;
4=Exceeds Expectations; 5=Outstanding; NA= Not Assessed 1 2 3 4 5 NA
Communication with patients (Major)
Communication with families (Major)
Written records (Major)
Communication with other health care professions (Major)
Please return to the Pediatric Undergraduate Medical Education Office (Children’s Hospital) CK239 - 840 Sherbook St., Winnipeg, MB, R3A 1S1
Yes
No (If No, why?):
file://///Ad.wrha.mb.ca/wrha/HSC/shared/CHP/CHP_PED_UNDERGRAD/Peds%20UGME/Clerkship/Clerkship%20Evaluation%20Forms/Original%20Word%20Versions/Peds%20Clerkship%20Evaluation%20Package.docfile://///Ad.wrha.mb.ca/wrha/HSC/shared/CHP/CHP_PED_UNDERGRAD/Peds%20UGME/Clerkship/Clerkship%20Evaluation%20Forms/Original%20Word%20Versions/Peds%20Clerkship%20Evaluation%20Package.doc
-
\\Ad.wrha.mb.ca\wrha\HSC\shared\CHP\CHP_PED_UNDERGRAD\Peds UGME\Clerkship\Clerkship Evaluation Forms\Original Word Versions\Peds Clerkship Evaluation Package.doc
26
SUBSPECIALTY – SESSION #2 Can Meds Role: Manager/Health Advocate/ Scholar
Date: Student (print name) Preceptor: Attending Resident (print name)
Signatures:
Medical Student Self Evaluation
What did I do well today?
After today, what do I need to work on?
Attending Evaluation
Do you agree with the self-evaluation?
What was the medical student’s strength today?
Identify one issue or skill for deeper/further learning:
CanMEDS role for today to be specifically assessed: MANAGER/ HEALTH ADVOCATE / SCHOLAR
1=Unsatisfactory; 2=Below Expectations; 3=Meets Expectations;
4=Exceeds Expectations; 5=Outstanding; NA= Not Assessed 1 2 3 4 5 NA
Time Management (organized, efficient, punctual) (Minor)
Health Promotion Strategies (Knows disease prevention, health promotion) (Minor)
Determinants of Health (understands social determinants affecting health) (Minor)
Self-directed learning (self-initiative, relevant reading) (Major)
Knowledge and application of evidence-based medicine (Minor)
Contributions to learning activities (enthusiasm, engagement) (Minor)
Oral presentations organization and relevance (Minor)
Please return to the Pediatric Undergraduate Medical Education Office (Children’s Hospital)
CK239 - 840 Sherbook St., Winnipeg, MB, R3A 1S1
Yes
No (If No, why?):
file://///Ad.wrha.mb.ca/wrha/HSC/shared/CHP/CHP_PED_UNDERGRAD/Peds%20UGME/Clerkship/Clerkship%20Evaluation%20Forms/Original%20Word%20Versions/Peds%20Clerkship%20Evaluation%20Package.docfile://///Ad.wrha.mb.ca/wrha/HSC/shared/CHP/CHP_PED_UNDERGRAD/Peds%20UGME/Clerkship/Clerkship%20Evaluation%20Forms/Original%20Word%20Versions/Peds%20Clerkship%20Evaluation%20Package.doc
-
\\Ad.wrha.mb.ca\wrha\HSC\shared\CHP\CHP_PED_UNDERGRAD\Peds UGME\Clerkship\Clerkship Evaluation Forms\Original Word Versions\Peds Clerkship Evaluation Package.doc
27
SUBSPECIALTY – SESSION #3 Can Meds Role: Professional
Date: Student (print name) Preceptor: Attending Resident (print name)
Signatures:
Medical Student Self Evaluation
What did I do well today?
After today, what do I need to work on?
Attending Evaluation
Do you agree with the self-evaluation?
What was the medical student’s strength today?
Identify one issue or skill for deeper/further learning:
CanMEDS role for today to be specifically assessed: PROFESSIONAL
1=Unsatisfactory; 2=Below Expectations; 3=Meets Expectations;
4=Exceeds Expectations; 5=Outstanding; NA= Not Assessed
1 2 3 4 5 NA
Integrity/Altruism (Honest, respectful, role model) (Major)
Responsibility and conscientiousness (prepared, engaged, model behaviour) (Major)
Self-assessment (seeks and responds well to feedback) (Minor)
Personal Demeanor (professional appearance, hygiene and conduct) (Minor)
Please return to the Pediatric Undergraduate Medical Education Office (Children’s Hospital)
CK239 - 840 Sherbook St., Winnipeg, MB, R3A 1S1
Yes
No (If No, why?):
file://///Ad.wrha.mb.ca/wrha/HSC/shared/CHP/CHP_PED_UNDERGRAD/Peds%20UGME/Clerkship/Clerkship%20Evaluation%20Forms/Original%20Word%20Versions/Peds%20Clerkship%20Evaluation%20Package.docfile://///Ad.wrha.mb.ca/wrha/HSC/shared/CHP/CHP_PED_UNDERGRAD/Peds%20UGME/Clerkship/Clerkship%20Evaluation%20Forms/Original%20Word%20Versions/Peds%20Clerkship%20Evaluation%20Package.doc
-
\\Ad.wrha.mb.ca\wrha\HSC\shared\CHP\CHP_PED_UNDERGRAD\Peds UGME\Clerkship\Clerkship Evaluation Forms\Original Word Versions\Peds Clerkship Evaluation Package.doc
28
SUBSPECIALTY – SESSION #4 Can Meds Role: Manager/Health Advocate/ Scholar
Date: Student (print name) Preceptor: Attending Resident (print name)
Signatures:
Medical Student Self Evaluation
What did I do well today?
After today, what do I need to work on?
Attending Evaluation
Do you agree with the self-evaluation?
What was the medical student’s strength today?
Identify one issue or skill for deeper/further learning:
CanMEDS role for today to be specifically assessed: MANAGER/ HEALTH ADVOCATE / SCHOLAR
1=Unsatisfactory; 2=Below Expectations; 3=Meets Expectations;
4=Exceeds Expectations; 5=Outstanding; NA= Not Assessed 1 2 3 4 5 NA
Time Management (organized, efficient, punctual) (Minor)
Health Promotion Strategies (Knows disease prevention, health promotion) (Minor)
Determinants of Health (understands social determinants affecting health) (Minor)
Self-directed learning (self-initiative, relevant reading) (Major)
Knowledge and application of evidence-based medicine (Minor)
Contributions to learning activities (enthusiasm, engagement) (Minor)
Oral presentations organization and relevance (Minor)
Please return to the Pediatric Undergraduate Medical Education Office (Children’s Hospital)
CK239 - 840 Sherbook St., Winnipeg, MB, R3A 1S1
Yes
No (If No, why?):
file://///Ad.wrha.mb.ca/wrha/HSC/shared/CHP/CHP_PED_UNDERGRAD/Peds%20UGME/Clerkship/Clerkship%20Evaluation%20Forms/Original%20Word%20Versions/Peds%20Clerkship%20Evaluation%20Package.docfile://///Ad.wrha.mb.ca/wrha/HSC/shared/CHP/CHP_PED_UNDERGRAD/Peds%20UGME/Clerkship/Clerkship%20Evaluation%20Forms/Original%20Word%20Versions/Peds%20Clerkship%20Evaluation%20Package.doc