Student Clinical Evaluation

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* 1. Student Name:

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* 2. Clinical Instructor Name:

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* 3. Clinical Instructor's Email:

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* 4. Practicum:

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* 6. 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, 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.

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* 7. Personal Safety: Follows Universal Precautions.

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

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* 9. Character Skills - Important:  Please rate the student on how well they demonstrated the following Important 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 N/A
1. Plans Effectively
2. Works with Appropriate Speed
3. Communicates Effectively
4. Adaptable/Flexible
5. Performs Well Under Stress

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

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* 11. Areas Needing Improvement and/or Strengths

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