Osteopathic Medical Student Clinical Performance Evaluation 2014 2015

Student:

Preceptor:

Course #

Site:

Clerkship Dates:

Specialty:

Deans Letter Summary (Please note all comments included in this box or the reverse page, unless otherwise labeled, will be put into the
students Deans Letter verbatim)

*Any additional comments not to be included in the Deans Letter, please use reverse side of this form or a separate correspondence and label as such.

Overall do you feel the student passed the rotation?

Would you recommend that this student receive honors for this clerkship?
Did student miss any dates or call shifts on this rotation?
Students performance by the rotations end.
(Please check one box for each section)
The student participates and performs in didactic sessions
The student is able to perform or explain procedures as expected for
current level of training
The student is able to perform H & P as expected for current level of
training
The student demonstrates appropriate use of osteopathic manipulative
medicine
The student applies osteopathic principles to diagnosis and treatment of
patients
The student displays evidence of ongoing awareness of the patients
condition and progress
The student is diligent at carrying out plans and communicating changes
with the patient
The student is knowledgeable about the patients condition and
differential diagnosis
The student shows signs of independent learning
The student shows signs of significant learning taking place during the
rotation
The student displays understanding of the use of evidence in clinical
decision making
The student refers to bibliographic resources while discussing clinical
topics
The student has a good work ethic
The student comported him/herself in a professional and appropriate
manner
The student is respectful toward peers, co-workers, attending and
resident physicians, patients and families
The student is able to communicate clearly and effectively to patients,
families and co-workers
The student is able to perform case presentations in a lucid and focused
manner.
The student understands and behaves appropriately in their role in the
system of medical care
The student is able to figure out how to accomplish tasks in patient care,
at a level commensurate with their degree of advancement

Preceptors Signature
Evaluation Reviewed with Student? Yes

No

Yes No Comments
Yes No Comments
Yes No Comments
No Basis
for
Opinion

Fails
Expectation

Misses
Expectation

Meets
Expectation

Exceeds
Expectation

Masters
Expectation

Honors

Date:
Students Signature

*Please provide a copy of this evaluation to the student after review.

Mail form to: Office of Clinical Education Touro University-CA College of Osteopathic Medicine, 1310 Club Drive, Vallejo, CA 94592;
Or Email to: mon.saepharn@tu.edu; Fax Not Recommended
If you have any questions, please contact Mon Saepharn (Grades Coordinator) phone: 707-638-5293