MEDICAL STUDENT CLINICAL EVALUATION FORM
DUKE UNIVERSITY SCHOOL OF MEDICINE
STUDENTS NAME: Last Name, First Name COURSE NAME & NUMBER: MEDICINE
COURSE WEIGHT: INSTRUCTOR:
DATES: dd/mm/2006 TO dd/mm/2006
GRADE: Honors (4) High Pass (3) Pass (2) Fail (1) Incomplete Circle the appropriate FINAL grade
Circle the appropriate numerical value for each applicable criteria. during period of
Application of Basic Science Fund of Knowledge to Clinical Setting
4 - Outstanding fund of knowledge; 3 - Solid fund of knowledge; applies 2 - Limited fund of knowledge; can 1 - Poor fund of knowledge; limited 0 - Not observed Y N N/A
superior, advanced skills applying to readily to clinical problems apply clinically: has potential for ability to apply clinically.
complex problems improvement
Interviewing Skills (check if evaluation is from direct observation and presentations or presentations alone)
4 -Excellent skills; thorough yet 3 - Organized, usually complete including 2 - Organized; obtains basic history 1 - Disorganized, incomplete, lacks 0 - Not observed Y N N/A
succinct and focused history. pertinent (+) & (-) ROS; but often with but points often missed including focus.
extraneous information. pertinent (+) & (-) ROS.
Physical Examination Skills (check if evaluation is from direct observation and presentations or presentations alone)
4 -Thorough and accurate; focused 3 - Complete; usually recognizes abnormal 2 - Generally complete but often 1 - Omits critical parts of the exam 0 - Not observed N N/A
relative to the history. findings misses significant abnormal findings. and/or deficient exam skills.
Presentation Skills (Formal presentations and during rounds/clinic)
4 -Consistently organized, logical, 3 - Presentations organized, logical; 2 - Generally complete; may lack 1 - Disorganized/ incomplete; by 0 - Not observed N N/A
complete; preparation does not highlights abnormal findings; preparation organization/ fail to highlight end, listeners uncertain of primary
require assistance. requires some assistance abnormal findings; needs much clinical problem/recent events.
Assessment, Formulation and Clinical Application Skills
4 - Consistently able to formulate 3 - Formulates assessment of major 2 - Usually handles major problem; 1 - Usually unable to formulate an 0 - Not observed N N/A
assessment of basic problems; also problem; may have trouble identifying/ may not integrate all aspects (H&P, assessment of basic medical
can prioritize multiple problems. prioritizing multiple problems. labs, rx); suggests elemental problems.
Ward/Clinic/Other Assigned Duties (orders, follow-up of tests)
4 - Takes patient responsibility; 3 - Active team member; takes significant 2 - Involved in ward/clinic duties but 1 - Not regularly involved in 0 - Not observed Y N N/A
comfortably evaluates/ manages responsibility for patient management. usually passive; follows direction of ward/clinic management.
multiple patients. others.
4 - Exceptional procedural skills. 3 - Competent basic procedural skills 2 - Mediocre procedural skills; 1 - Struggles with procedural skills; 0 - Not observed Y N N/A
makes effort and is improving. no effort to improve.
Record Keeping (Initial Work Up, Interval/Progress Notes)
4 - Accurate, thorough, and succinct 3 - Accurate data included with ongoing 2 - Includes basic information; 1 - Incomplete or erroneous. 0 - Not observed Y N N/A
(intern level). assessments of basic problems. rarely analyzes new data/ impact on
during period of
4 - Dependable; highly committed to 3 - Dependable team player and deliverer 2 - Fulfills basic responsibilities; 1 - Unreliable, often absent or late; 0 - Not observed Y
and enjoys clinical care. of patient care. little dedication or commitment to commitment uncertain.
Response to feedback
4 - Mature response; regularly seeks 3 - Mature response to feedback; strives 2 - Defensive response but does lead 1 - No insight into weaknesses; 0 - Not observed
Y N N/A
feedback and ways to improve. for improvement to change. rejects feedback; no behavior
Interactions with patients
4 - Extremely compassionate and 3 - Interacts well with patients and 2 - Often uncomfortable in patient 1 - Insensitive to needs, feelings, 0 - Not observed Y N/A
respectful with patients/families. families. interactions. values of patients.
Interactions with other members of health care team
4 - Interacts well; seeks contributions 3 - Interacts well with other health care 2 - Occasional difficulty interacting 1 - Avoids interactions; little respect 0 - Not observed N/A
of others on the health care team. team members. with others. for contributions of others.
Other (Course instructors’ criteria)
Excellent Good Satisfactory Unsatisfactory Not observed Y N N/A
Comments: (Please specify how grade was determined, including any test scores, and justification for all honors grades.)
Suggestions for improvement: (not to be included in Dean's letter for recommendation)