Osteopathic Medical Student Clinical Performance Evaluation 2017  – 2018 

Student:          Preceptor:            Course #       Site:             Clerkship Dates:           Specialty:      

Dean’s Letter Summary (Please note all comments included in this box or the reverse page, unless otherwise labeled, will be put into the students Dean’s Letter verbatim)      

 *Any additional comments not to be included in the Dean’s Letter, please use reverse side of this form or a separate correspondence and label as such.

Overall do you feel the student passed the rotation?  Would you recommend that this student receive Honors for this clerkship?  Did student miss any dates or call shifts on this rotation? 

Yes ☐  No ☐  Comments____________ 

Yes ☐  No ☐  Comments____________ 

Yes ☐  No ☐  Comments____________ 

AOA Competencies

Student’s performance by the rotation’s end (Please check one box for each section)

Fails Expectation

Misses Expectation 

Meet Expectation 

Exceeds Expectation

Masters Expectation

No Basis for  

Opinion

Professionalism Thestudentparticipatesandperformsindidacticsessions □ □ □ □ □ □

PatientCare

The student is able to perform or explain procedures as expected forcurrentleveloftraining □ □ □ □ □ □The student is able to performH&P as expected for current level oftraining □ □ □ □ □ □

OsteopathicPrinciplesandPractice

Thestudentdemonstratesappropriateuseofosteopathicmanipulativemedicine □ □ □ □ □ □Thestudentappliesosteopathicprinciplestodiagnosisandtreatmentofpatients □ □ □ □ □ □

Patientcare

Thestudentdisplaysevidenceofongoingawarenessofthepatient’sconditionandprogress □ □ □ □ □ □Thestudentisdiligentatcarryingoutplansandcommunicatingchangeswiththepatient □ □ □ □ □ □

MedicalKnowledge

Thestudentisknowledgeableaboutthepatient’sconditionanddifferentialdiagnosis □ □ □ □ □ □Thestudentshowssignsofindependentlearning □ □ □ □ □ □

PracticeBasedLearning&Improvement

The student showssignsof significant learningtakingplaceduring therotation □ □ □ □ □ □The student displays understanding of the use of evidence in clinicaldecisionmaking □ □ □ □ □ □The student refers to bibliographic resourceswhile discussing clinicaltopics □ □ □ □ □ □

Professionalism

Thestudenthasagoodworkethic □ □ □ □ □ □The student comported him/herself in a professional and appropriatemanner □ □ □ □ □ □Thestudentisrespectfultowardpeers,co‐workers,attendingandresidentphysicians,patientsandfamilies □ □ □ □ □ □

Interpersonal&Communication

Skills

The student is able to communicate clearly and effectively to patients,familiesandco‐workers □ □ □ □ □ □Thestudentisabletoperformcasepresentationsinalucidandfocusedmanner □ □ □ □ □ □

SystemsBasedPractice

Thestudentunderstandsandbehavesappropriately intheirrole inthesystemofmedicalcare □ □ □ □ □ □Thestudentisabletofigureouthowtoaccomplishtasksinpatientcare,atalevelcommensuratewiththeirdegreeofadvancement □ □ □ □ □ □

Preceptor’s Signature    Date:  Evaluation Reviewed with Student?  Yes     No      Student’s Signature  

*Please provide a copy of this evaluation to the student after review.

Mail form to: Office of Clinical Education Touro University‐CA College of Osteopathic Medicine, 1310 Club Drive, Vallejo, CA 94592; Or Email to: kimberly.black@tu.edu; Fax Not Recommended 

If you have any questions, please contact Kimberly Black, phone (707-638-5378)

Explanation of the Clinical Preceptor evaluation form

We appreciate the time that is required to evaluate these competencies. We ask that you allot a brief amount of time

available to meet with the students in the middle and the end of the rotation in order to apprise them of their progress

and performance. Please contact the Clinical Education Department with any concerns regarding individual student

progress.

Clinical Education Department contact information:

Comments entered here will be transcribed verbatim into the Medical Student Performance Evaluation (MSPE, or Dean’s Letter). We appreciate

your effort to comment in detail. Preceptor commentary is the single most important element of the MSPE.

Each subcategory of

the AOA

competencies is

evaluated on a 5

point Likert scale.

Each point is

assigned a percent

value (from 50% for

“Fails Expectations”

to 100% for

“Masters

Expectations”). It is

from this that

grades for all

electives and Year 4

rotations are

derived.

Please check this box to confirm

that the student has passed, or not

passed the overall experience.

Check the “No Bases for

Opinion” boxes if you did not

have the opportunity to

observe the categories during

the rotation.

In order for us to

process this

evaluation, please

make sure to provide

student and rotation

information including

course number,

dates, specialty and

preceptor’s name.

Do not forget to sign this document to validate it, and to email it

to our course coordinator Mon Saepharn.