St. Boniface · CK239 - 840 Sherbook St., Winnipeg, MB, R3A 1S1 St. Boniface \\Ad.wrha.mb.ca\wrha\HSC\shared\CHP\CHP_PED_UNDERGRAD\Peds UGME\Clerkship\Clerkship Evaluation Forms\Original

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

St. Boniface

\\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

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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


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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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.



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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 ______ _______



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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 ______ _______



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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: __________




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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



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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)





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PRECEPTOR EVALUATIONS OF MEDICAL CLERK

AMBULATORY (OPD) ROTATION

Student Name: ____________________________


St. Boniface



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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:



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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:




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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)



Yes

No (If No, why?):



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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:








CanMEDS role for today to be specifically assessed: MEDICAL EXPERT



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


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?):



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MINOR TREATMENT AREA (FAST TRACK) – SESSION #1 Can Meds Role: Professional


Signatures:








CanMEDS role for today to be specifically assessed: PROFESSIONAL



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)



Yes

No (If No, why?):



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MINOR TREATMENT AREA (FAST TRACK) – SESSION #2 Can Meds Role: Medical Expert/Communicator/Collaborator


Signatures:











1 2 3 4 5 NA















Yes

No (If No, why?):



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DERMATOLOGY or EXTRA CHILDREN’S EMERGENCY Can Meds Role: Professional


Signatures:











1 2 3 4 5 NA







Yes

No (If No, why?):



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GENERAL PEDIATRIC CLINICS – SESSION #1 Can Meds Role – Medical Expert/Communicator/Collaborator


Signatures:











1 2 3 4 5 NA















Yes

No (If No, why?):



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GENERAL PEDIATRIC CLINICS: Session #2 Can Meds Role: Manager, Health Advocate, Scholar


Signatures:








CanMEDS role for today to be specifically assessed: MANAGER, HEALTH ADVOCATE, SCHOLAR



1 2 3 4 5 NA










Yes

No (If No, why?):



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GENERAL PEDIATRIC CLINICS – SESSION #3 Can Meds Role: Professional


Signatures:











1 2 3 4 5 NA







Yes

No (If No, why?):



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PEDIATRIC UNDERGRADUATE MEDICAL EDUCATION

CLINICAL CLERKSHIP

PRECEPTOR EVALUATIONS OF MEDICAL CLERK NIGHT FLOAT ROTATION

Student Name: ____________________________




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NIGHT FLOAT EVALUATION PACKAGE – CALL #1


Signatures:










1 2 3 4 5 NA

Communication Skills

History

Physical Examination

Discussion and presentation

Time Management



Yes

No (If No, why?):



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Signatures:










1 2 3 4 5 NA


History



Time Management



Yes

No (If No, why?):



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Signatures:








1=Unsatisfactory; 2=Below Expectations; 3=Meets Expectations; 4=Exceeds Expectations; 5=Outstanding; NA= Not Assessed

1 2 3 4 5 NA


History



Time Management



Yes

No (If No, why?):



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PRECEPTOR EVALUATIONS OF MEDICAL CLERK

SUBSPECIALTY ROTATION

Student Name: ____________________________




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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:











1 2 3 4 5 NA















Yes

No (If No, why?):



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SUBSPECIALTY – SESSION #2 Can Meds Role: Manager/Health Advocate/ Scholar


Signatures:




















Yes

No (If No, why?):



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SUBSPECIALTY – SESSION #3 Can Meds Role: Professional


Signatures:











1 2 3 4 5 NA







Yes

No (If No, why?):



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SUBSPECIALTY – SESSION #4 Can Meds Role: Manager/Health Advocate/ Scholar


Signatures:




















Yes

No (If No, why?):

Documents

St. Boniface · CK239 - 840 Sherbook St., Winnipeg, MB, R3A 1S1 St. Boniface \\Ad.wrha.mb.ca\wrha\HSC\shared\CHP\CHP_PED_UNDERGRAD\Peds UGME\Clerkship\Clerkship Evaluation Forms\Original