Preceptor Evaluation of Student Form
Student
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First Name
Last Name
Preceptor
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
Clinical Site
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Practice Domain
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Good
Needs Mild Improvement
Needs Significant Improvement
N/A
Performs and accurately documents a comprehensive exam (including age appropriate developmental assessment)
Performs and accurately documents a symptom focused exam
Differentiates between normal and abnormal findings
Provides health promotion, disease prevention, health protection counseling. Anticipates educational needs of the patient
Appropriately orders screening and diagnostic tests and considers cost-effectiveness
Identifies patient differential diagnoses
Appropriately prioritizes health findings and need for Intervention
Formulates a mutually acceptable plan of care with the patient
Utilizes an evidence-based approach to care using current standards and guidelines
Collaborates effectively with various members of the healthcare team
Prescribes appropriate pharmacologic and non-pharmacologic therapy
Provides appropriate referrals to additional health providers and community resources
Provides appropriate patient follow-up instructions
Accurately documents patient interaction using SOAP format
Maintains patient privacy and confidentiality
Identifies patient care access limitations, financial limitations, home / family dynamics
Provides care considering patient cultural values with sensitivity to specific cultural beliefs
Demonstrates understanding of scope of practice and professional limitations
Utilizes time efficiently and effectively
Demonstrates self-direction and seeks new learning opportunities
Accepts and acts on feedback and constructive criticism
Demonstrates professional approach to patients and colleagues
Arrives promptly to clinical sites and maintains scheduled clinical hours agreed upon with preceptor
Demonstrates ethical decision making and behavior during patient interactions and development of a plan of care
Comments
Preceptor Signature
*
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