ICU Workplace-Based Assessment Form - GENERAL Initiated # ICU months: Name of Trainee: (Months of ICU rotation completed since beginning ☐ assessment: of CCM program) Initiated Name of Faculty: MM / DD / YY Date: ☐ assessment: ☐ ☐ ☐ ☐ Setting: ICU E.R. Ward Post-Op Unit ☐ Multidisciplinary ☐ ☐ EPA: Resuscitation New Consultation Rounds Type of assessment: ☐ ☐ ☐ Direct Observation Case Review Simulation Clinical activity directly Clinical activity retrospectively Clinical activity directly observed observed by supervisor in reviewed partially or fully by by supervisor in simulation real clinical setting. supervisor. setting. Complexity: ☐ ☐ ☐ Low Moderate High Routine clinical problem, Some elements of complexity in Complex and atypical clinical presentation, and clinical problem, presentation, and problem, presentation, and management. management. management. Brief case description: CHOOSE 2 AREAS OF FEEDBACK. For each, provide: 1) narrative comments on trainee's strengths, areas for development, and improvement strategies, and 2) choose a level of autonomy on the entrustment scale. NEEDS NEEDS NEEDS MINIMAL AUTONOMOUS EXPERT INTERVENTIONS DIRECTIONS GUIDANCE Able to do without Able to do in complex Unable to do without Partially able to do with Mostly able to do with guidance; refinement situations; personal others’ actions. others’ directions. minimal guidance. possible with feedback. insight on performance. Areas of feedback Feedback Narrative Comments ☐ Initial Stabilization Normalizing the vital signs of an unstable patient through appropriate and timely actions. INTERVENTION DIRECTION GUIDANCE AUTONOMOUS EXPERT ☐ ☐ ☐ ☐ ☐ Narrative Comments ☐ Clinical Assessment Gathering comprehensive and/or relevant information required for the elaboration of a INTERVENTION DIRECTION GUIDANCE AUTONOMOUS EXPERT diagnosis. ☐ ☐ ☐ ☐ ☐ Narrative Comments ☐ Diagnosis Generating differential, working, and definitive diagnoses on available clinical information. INTERVENTION DIRECTION GUIDANCE AUTONOMOUS EXPERT ☐ ☐ ☐ ☐ ☐ Narrative Comments ☐ Management / Clinical Judgment Making adequate decisions and taking appropriate actions when INTERVENTION DIRECTION GUIDANCE AUTONOMOUS EXPERT dealing with medical problems. ☐ ☐ ☐ ☐ ☐ Narrative Comments ☐ Communication
ICU Workplace-Based Assessment Form - GENERAL Name of Trainee: Initiated assessment: ☐ # ICU months: (Months of ICU rotation completed since beginning of CCM program) Name of Faculty: Initiated assessment: ☐ Date: MM / DD / YY Setting: ☐ ICU ☐ E.R. ☐ Ward ☐ Post-Op Unit EPA: ☐ Resuscitation ☐ New Consultation ☐ Multidisciplinary Rounds Type of assessment: ☐ Direct Observation Clinical activity directly observed by supervisor in real clinical setting. ☐ Case Review Clinical activity retrospectively reviewed partially or fully by supervisor. ☐ Simulation Clinical activity directly observed by supervisor in simulation setting. Complexity: ☐ Low Routine clinical problem, presentation, and management. ☐ Moderate Some elements of complexity in clinical problem, presentation, and management. ☐ High Complex and atypical clinical problem, presentation, and management. Brief case description: CHOOSE 2 AREAS OF FEEDBACK. For each, provide: 1) narrative comments on trainee's strengths, areas for development, and improvement strategies, and 2) choose a level of autonomy on the entrustment scale. NEEDS INTERVENTIONS Unable to do without others’ actions. NEEDS DIRECTIONS Partially able to do with others’ directions. NEEDS MINIMAL GUIDANCE Mostly able to do with minimal guidance. AUTONOMOUS Able to do without guidance; refinement possible with feedback. EXPERT Able to do in complex situations; personal insight on performance. Areas of feedback Feedback ☐ Initial Stabilization Normalizing the vital signs of an unstable patient through appropriate and timely actions. Narrative Comments INTERVENTION ☐ DIRECTION ☐ GUIDANCE ☐ AUTONOMOUS ☐ EXPERT ☐ ☐ Clinical Assessment Gathering comprehensive and/or relevant information required for the elaboration of a diagnosis. Narrative Comments INTERVENTION ☐ DIRECTION ☐ GUIDANCE ☐ AUTONOMOUS ☐ EXPERT ☐ ☐ Diagnosis Generating differential, working, and definitive diagnoses on available clinical information. Narrative Comments INTERVENTION ☐ DIRECTION ☐ GUIDANCE ☐ AUTONOMOUS ☐ EXPERT ☐ ☐ Management / Clinical Judgment Making adequate decisions and taking appropriate actions when dealing with medical problems. Narrative Comments INTERVENTION ☐ DIRECTION ☐ GUIDANCE ☐ AUTONOMOUS ☐ EXPERT ☐ ☐ Communication Narrative Comments
Assessment+Forms_GENERAL_July+2017.docx