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Resident Name
(Last Name, First Name)

Chief Complaint

Indicate the patient's chief complaint and presumptive diagnosis

Case Difficulty

Complicated (1) - Complicated. Atypical presentation, multiple additional medical problems, multiple past surgeries, communication or interpersonal barriers present. Chief level case.
Intermediate Difficulty (2) - Intermediate difficulty
Classic Presentation (3) - Classic presentation. Few or no additional medical problems, no related prior surgeries, no communication or interpersonal barriers. Appropriate for junior resident

Test Ordering and Understanding

Poor (1) - Poor. Tests recommended were not sufficient or appropriate for this patient. Resident had poor concept of test utility or cost/benefit for this patient
Fair (2) - Fair
Good (3) - Good. Recommended tests and procedures that were generally appropriate, though some were marginally useful. Little awareness of cost/benefits
Very Good (4) - Very Good
Excellent (5) - Excellent. Recommended tests and procedures that were clearly indicated by the findings; avoided over-ordering of tests; gave appropriate and clear instructions (e.g., fasting instructions) to patient to assure proper test administration and interpretation
N/A

Diagnostic Acumen

Poor (1) - Fails to recognize clinically obvious conditions; grossly inefficient in pulling together information to confirm the diagnosis; misjudges severity of patient condition
Fair (2)
Good (3) - recognizes obvious symptom patterns; reasonably efficient in pulling together information to confirm the diagnosis; misses some less obvious signs and symptoms
Very Good (4) - Very Good
Excellent (5) - Recognizes symptom patterns; includes appropriate alternatives in differential; efficient in pulling together information to confirm the diagnosis; takes appropriate steps to confirm the diagnosis
N/A

History Taking

Poor (1) - Poor. Missing important information, inefficient, disorganized; failed to check understanding of results
Fair (2) - Fair
Good (3) - Good Missing some minor facts but relatively precise, logical, purposeful and efficient
Very Good (4)
Excellent (5) - Precise, logical, purposeful and efficient; skillful at checking understanding of the findings
N/A

Physical Examination

Poor (1) - Poor technique, grossly inefficient, omitted key elements, missed some key signs, poor attention to patient modesty
Fair (2) - Fair
Good (3) - Good technique, reasonably efficient, omitted a few important elements, missed some signs
Very Good (4)
Excellent (5) - Excellent techniques, appropriately thorough, efficient, perceptive in picking up key signs
N/A

Communication Skills

Poor (1) - Explanation of presumed diagnosis and management were incorrect, missing or incomprehensible, poor rapport with patient, unprofessional at times, answers to patient questions were confusing or incorrect
Fair (2)
Good (3) - Explanation of presumed diagnosis and management were generally appropriate and free of medical jargon; appropriately empathetic; professional at all times; answers to patient questions were generally clear and accurate
Very Good (4)
Excellent (5) - xplained presumed diagnosis and management appropriately using vocabulary appropriate to the patient; established excellent rapport with patient; professional at all times; answered patient's questions clearly and accurately
N/A

Overall Comments