| CORE ROTATION INTERIM FEEDBACK FORM (IFF) | |||||
| Preceptor Name & Email: | |||||
| Student Name/ A#: | |||||
| Description of encounter directly observed: | "Example: Student performed an H&P in the ER with a patient suffering with a Headache" | ||||
| Core Learning Objectives | Scale (Please circle/ Mark all that apply) | Below Expected Level | At Expected Level | Above Expected Level | Preceptor Name & Signature and Date of Observation (Comments) |
| Clinical Skills | Performing a History & Examination | 1 | 2 | 3 | |
| History and Data Gathering | Ability to elicit a hypothesis driven clinical history in a fluent, professional and systematic way avoiding jargon | Disorganized questioning with use of jargon | Good systematic questioning minimal use of jargon | Very well organized and logical questioning no jargon | |
| Ability to elicit pertinent positive and negative information in the history | Minimal | Identified several | Identified most, very good use | ||
| Appropriate use of open-ended and closed questioning to evoke an accurate history | Poor use of questioning techniques | Appropriate use of questioning techniques | Above expected level use of questioning techniques | ||
| Physical Exam | Ability to examine components pertinent to history | Missed major physical examination components | Included most key physical examination components | Included all relevant physical examination components | |
| Appropriate examination skills and technique | Poor examination skills | Average examination skills | Superior examination skills | ||
| Accuracy of physical signs identified | Inaccurate physical or invented findings | Mostly accurate physical findings | All physical findings accurate | ||
| Communication | Ability to develop a harmonious relationship and to treat a patient respectfully and sensitively. | Lack of rapport, failure to act on verbal or nonverbal cues | Good rapport with patient. Recognizes and responds to verbal or nonverbal cues | Excellent rapport. Recognizes and responds to verbal or nonverbal cues. Develops a therapeutic alliance with patients. | |
| Ability to educate the patient and clearly explain illness / symptoms / management plan without jargon to ensure understanding | Poor ability to explain illness / symptoms / management plan to the patient | Good ability to explain illness / symptoms / management plan to the patient understanding of education /management | Excellent ability to explain illness / symptoms / management plan to the patient understanding of education /management | ||
| Ability to empathize and manage patient concerns | Poor ability to empathize and address patient concerns | Good and fairly consistent ability to empathize and address patient concerns | Consistently and effectively empathizes and addresses patient concerns | ||
| Case Presentation | Ability to present a complete and appropriately sequenced case highlighting the relevant findings. | Disorganized or incomplete case presentation | Organized case presentation with most exam features represented | Well organized and comprehensive case presentation | |
| Focus on salient features from history, examination and investigations to develop an accurate illness representation | Poor interpretation illness representation | Good general understanding illness representation | Excellent incorporation of all key features of illness representation | ||
| Medical Knowledge | 1 | 2 | 3 | ||
| Management Plan Development | Ability to develop a sensible differential diagnosis and safe management plan | Weak differential, missing most likely diagnosis. Poor management plan. | Reasonable differential but sub-optimal ordering of possible diagnoses. Good management plan | Excellent differential, identifies most likely diagnosis. Comprehensive management plan | |
| Ability to include supporting and opposing factors in prioritization | Missed most significant factors | Identified several important factors | Identified most important factors | ||
| Social Determinants | Ability to incorporate aging, psychological, cultural, environmental, genetic, nutritional, social, economic, religious and developmental impact factors on health and disease of patients as well as their impact on families and caregivers. | Poor understanding of social determinants | Good understanding of social determinants | Excellent understanding of social determinants | |
| Patient Education | Ability to provide appropriate patient education regarding prevention, health problems and health maintenance. | Poor understanding of education | Good understanding of education | Excellent understanding of education | |
| Professionalism | 1 | 2 | 3 | ||
| Sensitivity | Ability to demonstrate sensitivity to issues related to culture, race, age, gender, religion, sexual orientation and disability in the delivery of health care. | Inconsistent sensitivity | Consistent sensitivity | Exceptional sensitivity | |
| Responsibility | Demonstrates responsibility in tasks dealing with patient care, faculty and colleagues including healthcare documentation and time management. | Inconsistent responsibility | Consistent responsibility | Exceptional responsibility | |
| Situation | Accepts criticism and reacts appropriately to difficult situations involving conflicts, nonadherence, and ethical dilemmas | Inconsistent accepting criticism and reacting appropriately | Consistent in accepting criticism and reacting appropriately | Exceptional in accepting criticism and reacting appropriately | |
| Comments (optional) | |||||