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St. Boniface
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
Ambulatory (OPD) Evaluation (St. Boniface).doc 2
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:
Ambulatory (OPD) Evaluation (St. Boniface).doc 3
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
Ambulatory (OPD) Evaluation (St. Boniface).doc 4
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)
Yes
No (If No, why?):
Ambulatory (OPD) Evaluation (St. Boniface).doc 5
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?):
Ambulatory (OPD) Evaluation (St. Boniface).doc 6
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 behavior)(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?):
Ambulatory (OPD) Evaluation (St. Boniface).doc 7
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?):
Ambulatory (OPD) Evaluation (St. Boniface).doc 8
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)
Yes
No (If No, why?):
Ambulatory (OPD) Evaluation (St. Boniface).doc 9
DERMATOLOGY/EXTRA CHILDREN’S EMERGENCY OR EXTRA SUBSPECIALTY CLINIC 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 behavior)(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?):
Ambulatory (OPD) Evaluation (St. Boniface).doc 10
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 behavior)(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?):
Ambulatory (OPD) Evaluation (St. Boniface).doc 11
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)
Yes
No (If No, why?):
Ambulatory (OPD) Evaluation (St. Boniface).doc 12
SUBSPECIALTY CLINIC EVALUATION– 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?):
Ambulatory (OPD) Evaluation (St. Boniface).doc 13
SUBSPECIALTY CLINIC EVALUATION – SESSION #2 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 behavior)(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?):
Ambulatory (OPD) Evaluation (St. Boniface).doc 14
Max Rady College of Medicine Department of Pediatrics & Child Health
Assessment of Clinical Skill (Student Assessment) #1
Medical Student: Nurse Preceptor:
Please evaluate this session by marking the appropriate boxes below.
SESSION 1 1 2 3 4 5
Identifies the risks and benefits associated with IV insertion.
Identifies strategies to manage pain and anxiety.
Identifies appropriate anatomic site for IV insertion.
Practices infection control around IV insertion.
Successfully inserts an IV.
SESSION 2
Identifies strategies to preserve and maintain IV site.
Communicates accurate assessment of IV site health to members of the healthcare team.
1 – Is unable to perform the task/declines attempting to perform the task/only observes the task/needed to do the task for them. 2 – Attempts the task, but needed to be guided through every step of the process. 3 – Attempts the task with occasional prompting. 4 – Completes the task adequately with observation; may not be aware of risks or complications that still require observation. 5 – Performs the task independently and identifies/understands the risks involved.
Comments (strengths and areas to work on):
Please return to the Pediatric Undergraduate Medical Education Office (Children’s Hospital) CK239 - 840 Sherbook St., Winnipeg, MB, R3A 1S1
Ambulatory (OPD) Evaluation (St. Boniface).doc 15
Max Rady College of Medicine Department of Pediatrics & Child Health
Assessment of Clinical Skill (Student Assessment) #2
Medical Student: Nurse Preceptor:
Please evaluate this session by marking the appropriate boxes below.
SESSION 1 1 2 3 4 5
Identifies the risks and benefits associated with IV insertion.
Identifies strategies to manage pain and anxiety.
Identifies appropriate anatomic site for IV insertion.
Practices infection control around IV insertion.
Successfully inserts an IV.
SESSION 2
Identifies strategies to preserve and maintain IV site.
Communicates accurate assessment of IV site health to members of the healthcare team.
1 – Is unable to perform the task/declines attempting to perform the task/only observes the task/needed to do the task for them. 2 – Attempts the task, but needed to be guided through every step of the process. 3 – Attempts the task with occasional prompting. 4 – Completes the task adequately with observation; may not be aware of risks or complications that still require observation. 5 – Performs the task independently and identifies/understands the risks involved.
Comments (strengths and areas to work on):
Please return to the Pediatric Undergraduate Medical Education Office (Children’s Hospital) CK239 - 840 Sherbook St., Winnipeg, MB, R3A 1S1
