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M3 Emergency Medicine Specialty Clerkship Preceptor Evaluation
Student Name:
*
Date of Rotation:
*
+
Rotation Shift:
*
Preceptor Name:
*
Clinical Performance
1) Identify pertinent history elements in common presenting conditions
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Required complete guidance or was unprepared for task/skill
Performed task/skill but required detailed directions
Performed task/skill with only intermittent prompting
Performed task/skill independently, only needed assistance with nuances or complex aspects of cases
Did not observe
2) Obtain appropriate collateral information when needed
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Required complete guidance or was unprepared for task/skill
Performed task/skill but required detailed directions
Performed task/skill with only intermittent prompting
Performed task/skill independently, only needed assistance with nuances or complex aspects of cases
Did not observe
3) Utilize focused chart review to guide the visit
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Required complete guidance or was unprepared for task/skill
Performed task/skill but required detailed directions
Performed task/skill with only intermittent prompting
Performed task/skill independently, only needed assistance with nuances or complex aspects of cases
Did not observe
4) Perform a physical exam appropriate to the presenting problem or visit type
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Required complete guidance or was unprepared for task/skill
Performed task/skill but required detailed directions
Performed task/skill with only intermittent prompting
Performed task/skill independently, only needed assistance with nuances or complex aspects of cases
Did not observe
5) Identify abnormal physical exam findings
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Required complete guidance or was unprepared for task/skill
Performed task/skill but required detailed directions
Performed task/skill with only intermittent prompting
Performed task/skill independently, only needed assistance with nuances or complex aspects of cases
Did not observe
6) Develop a differential diagnosis for new problems (with at least 3 diagnoses)
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Required complete guidance or was unprepared for task/skill
Performed task/skill but required detailed directions
Performed task/skill with only intermittent prompting
Performed task/skill independently, only needed assistance with nuances or complex aspects of cases
Did not observe
7) Integrate emerging information to update differential diagnosis
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Required complete guidance or was unprepared for task/skill
Performed task/skill but required detailed directions
Performed task/skill with only intermittent prompting
Performed task/skill independently, only needed assistance with nuances or complex aspects of cases
Did not observe
8) Recommend first-line diagnostic evaluation for common conditions
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Required complete guidance or was unprepared for task/skill
Performed task/skill but required detailed directions
Performed task/skill with only intermittent prompting
Performed task/skill independently, only needed assistance with nuances or complex aspects of cases
Did not observe
9) Provide rationale for ordering studies
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Required complete guidance or was unprepared for task/skill
Performed task/skill but required detailed directions
Performed task/skill with only intermittent prompting
Performed task/skill independently, only needed assistance with nuances or complex aspects of cases
Did not observe
10) Interpret the results of basic diagnostic studies (labs and imaging)
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Required complete guidance or was unprepared for task/skill
Performed task/skill but required detailed directions
Performed task/skill with only intermittent prompting
Performed task/skill independently, only needed assistance with nuances or complex aspects of cases
Did not observe
11) Document the reasoning supporting clinical decisions
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Required complete guidance or was unprepared for task/skill
Performed task/skill but required detailed directions
Performed task/skill with only intermittent prompting
Performed task/skill independently, only needed assistance with nuances or complex aspects of cases
Did not observe
12) Provide a well-organized oral presentation
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Required complete guidance or was unprepared for task/skill
Performed task/skill but required detailed directions
Performed task/skill with only intermittent prompting
Performed task/skill independently, only needed assistance with nuances or complex aspects of cases
Did not observe
13) Recognize the severity of illness and indications to escalate care
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Required complete guidance or was unprepared for task/skill
Performed task/skill but required detailed directions
Performed task/skill with only intermittent prompting
Performed task/skill independently, only needed assistance with nuances or complex aspects of cases
Did not observe
14) Demonstrate curiosity and ask questions
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Required complete guidance or was unprepared for task/skill
Performed task/skill but required detailed directions
Performed task/skill with only intermittent prompting
Performed task/skill independently, only needed assistance with nuances or complex aspects of cases
Did not observe
15) Participate respectfully as part of an interdisciplinary team
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Required complete guidance or was unprepared for task/skill
Performed task/skill but required detailed directions
Performed task/skill with only intermittent prompting
Performed task/skill independently, only needed assistance with nuances or complex aspects of cases
Did not observe
16) Recognize the scope of their abilities, asking for assistance appropriately
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Required complete guidance or was unprepared for task/skill
Performed task/skill but required detailed directions
Performed task/skill with only intermittent prompting
Performed task/skill independently, only needed assistance with nuances or complex aspects of cases
Did not observe
17) Engage in daily safety habits (e.g., universal precautions, hand washing, time-outs).
*
Required complete guidance or was unprepared for task/skill
Performed task/skill but required detailed directions
Performed task/skill with only intermittent prompting
Performed task/skill independently, only needed assistance with nuances or complex aspects of cases
Did not observe
18) Use feedback to improve performance
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Required complete guidance or was unprepared for task/skill
Performed task/skill but required detailed directions
Performed task/skill with only intermittent prompting
Performed task/skill independently, only needed assistance with nuances or complex aspects of cases
Did not observe
19) Professionalism ( i.e. is on time, professional appearance, sensitive to diverse population, respects confidentiality and demonstrates honesty)
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Major Concerns
Minor Concerns
No Concerns
Comments:
Global Assessment: Compared to other students with a similar level of experience, this student’s performance today was:
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Lower 1/3
Middle 1/3
Top 1/3
Top 10%
Please provide specific feedback or comments for the student:
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