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* 1. Student Name:

* 2. Instructor Name:

3. Instructor Email Address:

The following evaluation shall reflect the level of the graduate student relative to the behavioral objectives while they are on specific clinical rotations. Indicate clinical area & appropriate response to the evaluation.

5. Type of Anesthesia:

7. Rating Scale: 5 - No assistance required; 4 - Minimal assistance required; 3 - Appropriate assistance required for level; 2 - Extensive assistance OR did not understand theory after explanation; 1 - Could not perform without assistance.

  5 4 3 2 1 N/A
1. Planning & Assessment: Student is able to assess patient status, formulate care plan, demonstrate accurate knowledge, write appropriate orders, select, set-up & implement suitable monitoring. Plans appropriate regional.
2. Induction: Student selects appropriate drugs/techniques, follows steps of induction & adjusts technique as necessary, recognizes & maintains patent airway, follows through with post-induction assessment, & intraoperative management. Performs regional with necessary assistance & assesses results.
3. Maintenance: Student assists in positioning the patient to prevent injury & promote physiologic functioning, monitors all parameters of patient status, observes surgical field & relates to anesthetic considerations & complications, identifies ventilatory & fluid resuscitation needs. Monitors regional level & effectiveness.
4. Emergence: Times emergence with completion of surgery, follows proper sequencing for extubation, evaluates & maintains patent airway post-extubation/emergence. Evaluates progression & level of regional.
5. Transport: Students transports the patient to the PACU, maintaining adequate airway & patient safety. Complete report given to appropriate nursing personnel.
6. Dexterity: Student has ability to intubate with smooth & atraumatic technique, insert appropriate monitoring lines, performs, regional blocks with assistance as necessary, inserts LMA's, manages & ventilates mask cases.
7. Reliability: Student carries out assignments, releives at appropriate & correct times; professionalism is reflected in attitude toward other graduate students, instructors, OR staff, surgeons, patients & families.

* 8. Personal Safety: Follows Universal Precautions.

9. Did the student demonstrate the Essential Character Skills: Honesty, Punctuality & Eagerness to Learn?

10. Character Skills - Important:
Please rate the student on how well they demonstrated the following Imporant Character Skills. Rating Scale: 5 - Exceptional use of skill; 4 - Above average use of skill; 3 - Average use of skill; 2 - Needed direction pertaining to skill; 1 - Needs immediate assistance with skill.

  5 4 3 2 1
1. Plans Effectively
2. Works with Appropriate Speed
3. Communicates Effectively
4. Adaptable/Flexible
5. Performs Well Under Stress

* 11. Did you discuss this evaluation with the student?

12. Areas Needing Improvement and/or Strengths: