Sample Clinical Communication Forms Overall Clinical Performance Student’s Name:_____________________________ Student’s Class/Level:_______________________ Name of Rotation: ___________________________Dates of Rotation:_____________________________ Please circle the description that best represents the student’s performance in each area. Demonstrates Applies Applies Clinical Needs Lacking basic knowledge to knowledge knowledge improvement knowledge cases consistently Complete, Inconsistent, History Complete and quickly asks looks at Inaccurate misses major taking accurate for important related points information findings Physical Complete but Thorough and mistakes Inconsistent examines exam slow efficient related Understands Data Identifies Integrates data problem and presentation Confusing and Misses problems and and includes demonstrates (written and vague important data prioritizes additional integration of verbal) them data data Care plan is Implements com-prehensive clinical Care plan is and is Poorly created Appropriate instructor’s Care plan complete and implemented and confusing but incomplete instructions, efficiently and partial adapted understanding appropriately Involves family Provides in education Patient Provides basic education and and education Minimal or education, Doesn’t provide counseling, counseling, and confusing minimal checks patient docu-ments counseling counseling understanding education provided Excellent, Communicates Communicates handles caring and or Polite clearly, listens difficult concern, puts skills judgmental well situations others at ease calmly Cooperative Takes and initiative to be Demonstrates Uncooperative Inconsistent responsible, involved and leadership, not late or presents self earns respect untidy well Learns Asks good Attitude independently, questions, toward Negative Disinterested Interested contributes to demonstrates learning improving extra effort learning
Sample Clinical Communication Forms Overall Clinical Performance Student’s Name:_____________________________ Student’s Class/Level:_______________________ Name of Rotation: ___________________________Dates of Rotation:_____________________________ Please circle the description that best represents the student’s performance in each area. Clinical knowledge Lacking Needs improvement Demonstrates basic knowledge Applies knowledge to cases Applies knowledge consistently History taking Inaccurate Inconsistent, misses major points Complete and accurate Complete, quickly asks for important information looks at related findings Physical exam mistakes Inconsistent Complete but slow Thorough and efficient examines related Data presentation (written and verbal) Confusing and vague Misses important data Identifies problems and prioritizes them Understands problem and demonstrates integration of data Integrates data and includes additional data Care plan Poorly created and confusing Appropriate but incomplete Implements clinical instructor’s instructions, partial understanding Care plan is complete and Care plan is com-prehensive and is implemented efficiently and adapted appropriately Patient education and counseling Doesn’t provide Minimal or confusing Provides basic education, minimal counseling Provides education and counseling, checks patient understanding Involves family in education and counseling, docu-ments education provided skills or judgmental Polite Communicates clearly, listens well Communicates caring and concern, puts others at ease Excellent, handles difficult situations calmly Uncooperative Inconsistent Cooperative and responsible, not late or untidy Takes initiative to be involved and presents self well Demonstrates leadership, earns respect Attitude toward learning Negative Disinterested Interested Asks good questions, demonstrates extra effort Learns independently, contributes to improving learning