ELECTIVE INTERESTING CASE PRESENTATION EVALUATION FORM

Elective Interesting Case Presentation Evaluation Form

Student Rotation Type Site Faculty

Date

Rotation Dates Preceptor Name

\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\ SCORING: 0 = Not done, 1/5 = Poor, 5/5 = Excellent

TOPIC: COMMENTS

HISTORY:

Descriptors included in HPI

0 1 2 3 4 5 Clear&conciseHPI 0 1 2 3 4 5 HPI includes pertinent positive and negatives 0 1 2 3 4 5 Includes all pertinent past medical history 0 1 2 3 4 5

PHYSICAL EXAM:

Focused physical exam-including all components 0 1 2 3 4 5 Includes pertinent positive & negative PE findings 0 1 2 3 4 5

LABS/DIAGNOSTIC PROCEDURES:

Utilization of appropriate diagnostic tests 0 1 2 3 4 5 Presents pertinent findings 0 1 2 3 4 5

DIAGNOSIS:

Addresses both acute, chronic disease & HCM 0 1 2 3 4 5 Ability to formulate & eliminate differential dx 0 1 2 3 4 5 Describes pathophysiology of disease state 0 1 2 3 4 5

MANAGEMENT:

Understands pharmacologic therapy 0 2 4 6 8 10 Discusses appropriate non-pharmacologic therapy 0 1 2 3 4 5 Addresses disease prevention/HCM 0 2 4 6 8 10 Provides patient with follow-up instructions 0 1 2 3 4 5

PATIENT EDUCATION:

Development of patient education materials 0 2 4 6 8 10

PROFESSIONALISM:

0 1 2 3 4 5

TOTAL POINTS

Faculty Signature: Date: __