EVALUATION OF  Return to: Dept. of Osteopathic Medical Educ.
Your logo INTERN / RESIDENT                     your address
PERFORMANCE                     your city, State, zip
NAME         SERVICE              DATES      
Please indicate the level of competency with consideration to level of training.  A rating of 1 must be accompanied by
an action plan or recommendation for remediation.
Deficient Usually      Meets Competencies Consistently Meets Competencies Exceptional Does Not Apply
COMPETENCY RANGE → Circle one rating   
Patient Care: 
Compassionate, appropriate and effective for the promotion of health, prevention & treatment of illness, and end of life
1. Gathered accurate, essential information from all sources:interviews, physical examinations, records, procedures  
1 2 3 4 X
Comments:
                           
2. Counseled patients and families about preventive, diagnostic, and therapeutic interventions based on clinical judgment, current scientific evidence, and patient preference
1 2 3 4 X
Comments:
                           
3. Performed competently the diagnostic and therapeutic procedures considered essential to the practice of medicine
1 2 3 4 X
Comments:
                           
4. Effectively worked with other health care providers to make appropriate referrals for treatment or health care services
1 2 3 4 X
Comments:
                           
Medical Knowledge:
Demonstrate knowledge of established and evolving biomedical, clinical, and social sciences
1. Applied open-minded, analytical approach to acquiring new knowledge
1 2 3 4 X
Comments:
                           
2. Developed applicable knowledge of basic and clinical sciences 1 2 3 4 X
Comments:
                           
3. Applied knowledge to clinical problem-solving, decision-making, and critical thinking
1 2 3 4 X
Comments:
                           
Practice-Based Learning: 
Use scientific evidence and methods to investigate, evaluate, and improve patient care practice
1. Implemented strategies to enhance knowledge, skills, attitudes and processes of care for the most up-to-date medical information
1 2 3 4 X
Comments:
                           
2. Developed and maintained willingness to learn from errors and improve system or processes of care
1 2 3 4 X
Comments:
                           
3. Used information technology or other available methodologies to access and manage information, support patient care decisions, and enhance both patient and physician education
1 2 3 4 X
Comments:
                           
Interpersonal & Communication Skills: 
Demonstrate interpersonal & communication skills to establish professional relations
1. Provided effective and professional consultation to other physicians and health care professionals 
1 2 3 4 X
Comments:
                             
2. Used effective listening, questioning and narrative skills to communicate with patients and families, being sensitive to cultural, religious, and language issues
1 2 3 4 X
Comments:                                
PLEASE CONTINUE EVALUATION ON REVERSE SIDE
Deficient Usually      Meets Competencies Consistently Meets Competencies Exceptional Does Not Apply
COMPETENCY RANGE → Circle one rating   
Continue Interpersonal & Communication Skills
3. Sustained ethically sound professional relationships with patients, families and colleagues. 
1 2 3 4 X
Comments:
                           
4. Maintained comprehensive, timely and legible medical records 1 2 3 4 X
Comments:
                           
Professionalism: Behaviors reflect continuous professional development, ethical practice, sensitivity to diversity, and
responsible attitude toward patients, profession, and society
1. Demonstrated respect, compassion, and integrity in relationships with patients, families, and colleagues 1 2 3 4 X
Comments:
                           
2. Demonstrated proper attention to issues of culture, religion, age, gender, sexual orientation, and mental/physical disabilities 1 2 3 4 X
Comments:
                           
3. Sustained ethically sound professional relationships with patients, families and colleagues.  1 2 3 4 X
Comments:
                           
4. Adhered to policies and guidelines for professional appearance and appropriateness of uniforms 1 2 3 4 X
Comments:
                             
Systems Based Practice: 
Demonstrate an understanding of the contexts and systems in which health care is provided
1. Demonstrated cost effective health care and resource allocation without compromising quality of care
1 2 3 4 X
Comments:
                           
2. Advocate for quality patient care: assisted patients in dealing with system complexities 1 2 3 4 X
Comments:
                           
3. Partnered with health care managers and providers to assess, coordinate, and improve health care 1 2 3 4 X
Comments:
                           
Osteopathic Principles & Practice: 
Demonstrate an understanding and awareness of the appropriatgeness of OMM
1. Demonstrated knowledge of osteopathic principles; can formulate treatment plan 1 2 3 4 X
Comments:
                           
2. Demonstrated clinical thinking which incorporates structure/function interrelation 1 2 3 4 X
Comments:
                           
3. Actively pursued the application of Osteopathic Manipulative Medicine to clinical cases 1 2 3 4 X
Comments:
                           
REQUIRED DOCUMENTATION (Strengths / Areas of Improvement, Supporting comments)
                         
                         
OVERALL EVALUATION Check one box please
Recommend advancement in the training program  
Recommend remediation of this rotation  
Preceptor Signature                 Date  
Intern Signature                 Date  
The requirements of this rotation did not violate the 80 work policy Initial  
Reviewed by Program Director (initial)    Date