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1. Student Name:

2. Instructor Name:

The following evaluation shall reflect the level of the graduate student relative to the behavioral objectives while they are on specific clinical rotations. Please fill out an evaluation for the overall progress/needs on a weekly basis. Any specific concerns about an individual cae can be addressed in the comments section.

3. Rotation:

4. Practicum:

5. Type of Anesthesia:

6. Rating Scale: 5 - No assistance/able to performe independantly; 4 - Minimal assistance/demonstrates more advanced level of competence; 3 - Appropriate assistance/basic understanding of specialty anesthesia; 2 - Extensive assistance/minimal understanding of specialty anesthesia; 1 - No understanding of basic specialty principals.

  5 4 3 2 1 N/A
1. Planning & Assessment: Student is able to assess patient status, demonstrates understanding of specialty anesthesia principals, analyzes the specialty patient history& physical status & plans appropriate anesthesia (Regional or General). Provides patient education & informed consent.
2. Induction: Student selects appropriate drugs, positions patient for optimal physiologic function, performs planned regional/general anesthetic with understanding of underlying specialty principles. Emergency equipment available.
3. Maintenance: Student assists in positioning the patient to prevent injury & promote physiologic functioning, monitors all parameters, monitors level & effectivementss of regional blocks, demonstrates appropriate management of the general anesthetic. Appropriate dosing & sequencing of required medications specific to that patient population.
4. Emergence: Student times emergence of GA with completion of surgical procedure, insuring patient ability to maintain airway. Doses/redoeses with appropriate medications. Evaluates levels and recovery needs of specialty patient.
5. Transport: Students transports the specialty patient, maintaining adequate airway & patient safety. Complete report given to appropriate nursing personnel. Recognizes & treates potential complications associated with the specialty patient.
6. Dexterity: Student has ability to intubate with smooth & atraumatic technique, insert appropriate monitoring lines, performs regional blocks with assistance as necessary & demonstrates progressive improvement in ability to perform blocks.
7. Reliability: Student carries out assignments, relieves at appropriate & correct times; professionalism is reflected in attitude toward other graduate students, instructors, OR staff, surgeons, patients & families.

7. Personal Safety: Follows Universal Precautions.

8. Progress: Student is progression as planned through the clinical rotation.

9. Character Skills - Essential Characteristics:

  Yes No
1. Honesty
2. Punctual
3. Reliable
4. Communicates Effectively
5. Eager to Learn

10. Character Skills - Important Characteristics:

  Yes No
1. Plans Effectively
2. Works with Appropriate Speed
3. Enthusiastic
4. Adaptable/Flexible
5. Performs Well Under Stress