CLINICAL SKILLS ASSESSMENT FORM

☐ I attest that I have not provided direct health care services to this student

Housestaff potential:

☐ Unsatisfactory                 ☐Satisfactory       ☐ Good                 ☐ Excellent          ☐Not observed

Grade:

☐Fail                                     ☐Pass                    ☐High Pass           ☐Honors                      ☐Incomplete

Comments (please specify how grade was determined, including any test scores and justification for all Honors grades):

Strengths:

Suggestions for Improvement:

Please indicate whether this student demonstrated each the following behaviors.  To assist the student, place a check mark(s) next to skills which need improvement.

1. History

Obtains a focused, complete pertinent history in an organized fashion

☐No                      ☐Partially             ☐Yes                     ☐Not observed

Areas for Improvement (check all that apply):

                Patient-centeredinterview skills

Clinical reasoning to help focus questions

Organization and efficiency in obtaining information

☐Identifying pertinent history elements

☐Demonstrating cultural awareness

Completeness of history, include more key elements

Focusing the history

☐Including relevant positive and negative elements

Questioning technique

☐Use direct patient data versus medical record

Additional comments/Other:

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2. Physical exam

Performs a clinically relevant focused physical exam pertinent to the patient’s visit

☐No                      ☐Partially             ☐Yes                     ☐Not observed

Areas for Improvement (check all that apply):

                Efficiency in gathering exam information

Focus PE exam based on patient’s history

Thoroughness

Interpretation of findings

☐Identify pertinent negative findings

Basic exam techniques (specify the body system(s)):

Clerkship specific exam techniques

☐Observing cultural/gender/race concerns

Additional comments/Other:

3. Differential Diagnosis

Develops a focused appropriate differential diagnosis for patients problem

☐No                      ☐Partially             ☐Yes                     ☐Not observed

Areas for Improvement (check all that apply):

                ☐Developing a reasonable focused working diagnosis

                ☐Critically evaluating the findings supporting the differential

                ☐Identifying inconsistencies in exam or history with the differential

                ☐Focusing differential on the most likely explanationsfor the patient’s problem

                ☐Organizing the differential on likelihood

                ☐Documenting the clinical reasoning that supports the differential

                ☐Using information technology to refine differential

                ☐Use new information to update/prioritize differential

Additional comments/Other:

4. Diagnostic studies

Recommends an appropriate diagnostic plan and provides rationale

☐No                      ☐Partially             ☐Yes                     ☐Not observed

Areas for Improvement (check all that apply):

                ☐Prioritizing diagnostic tests

                ☐Appropriate testing for patient’s condition

                ☐Rationale for ordering tests

☐Using EBM/clinical reasoning for testing decisions

Cost-awareness/risk-benefit analysisin testing

                ☐Interpretingresultsof basic diagnostic studies

☐Recognizing abnormaltest results

Additional comments/Other:

5.  Assessment

Identifies key clinical questions and retrieves appropriate scientific evidence in care of patients

☐No                      ☐Partially             ☐Yes                     ☐Not observed

Areas for Improvement (check all that apply):

                ☐Focusing pertinent clinical questions

                ☐Evaluating quality of scientific evidence

                Usingscientific evidence to assist withpatient care

                ☐Communicating findings to the health care team

☐Demonstrate more curiosity

Additional comments/Other:

6.  Documentation

Provides accurate, focused and well organized documentation of clinical encounter

☐No                     ☐Partially           ☐Yes                    ☐Not observed

Areas for Improvement (check all that apply):

               ☐Efficiency of documentation

☐Accuracy of documentation (specify):

Organizinga problem list

               Rationalizingthe differential diagnosis

               ☐Creating afocused differential

               ☐ Organizing & prioritizing information

               ☐ Formulatinga management plan

               ☐ Synthesizing information into a cogent narrative

☐Include more clinical reasoning in notes

               Timeliness of record documentation

Additional comments/Other:

7.  Oral Presentations

Oral presentation is accurate, organized and concise

☐No                      ☐Partially             ☐Yes                     ☐Not observed

Areas for Improvement (check all that apply):

                Organization of presentations

                ☐Being more concise in presentations

                ☐Focusing on the key patient specific elements of a presentation

                ☐Including more pertinent positives and negatives

                ☐Better highlighting the key active issues

                ☐Communicating areas of uncertainty

                ☐Modifying presentationbased on audience, amount of time, purpose, and specialty

                ☐Preserving patient confidentiality and privacy

Additional comments/Other:

8.  Interprofessional Interactions

Interacts appropriately with different health professionals based on their role in the care of an individual patient

☐No                      ☐Partially             ☐Yes                     ☐Not observed

Areas for Improvement (check all that apply):

                ☐Contributing within one’s roleto optimize care and team functioning

                ☐Understandingof the roles of health professionals

                ☐Respecting and appreciating team members

                ☐Ask more clarifying questions when uncertain

                ☐Listen more carefully

Additional comments/Other:

9. Professionalism

Student demonstrates all aspects of professionalism in interactions with others

☐No                      ☐Partially             ☐Yes                     ☐Not observed

Areas for Improvement (check all that apply):

Compassion and respect for patients/families

 ☐Balancing personal and patient care needs

Interactions with other members of the health care team

Dependability in fulfilling responsibilities

Timeliness

Utilizing feedback to improve performance

☐Recognizing one’sown personal limits and when to seek assistance

Additional comments/Other:

Signature: _____________________________________________     Date:  ____________________________