CLINICAL YEAR FORMS

Interesting Case Presentation Evaluation Form

Student Faculty

Rotation Type Site 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 & concise HPI 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

JOURNAL:

Discusses or writes a summary of article Submits supporting journal article (< 5yrs old) 0 2 4 6 8 10

PROFESSIONALISM:

0 1 2 3 4 5

TOTAL POINTS

Faculty Signature: Date: __

Elective Interesting Case Presentation Evaluation Form

Student Faculty

Rotation Type Site 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 & concise HPI 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: __

Mid-Clerkship Evaluation

Please complete this evaluation by the end of the third week of the clerkship. The midclerkship evaluation is designed to have students reflect on their strengths and weaknesses at the mid-point of their clerkship. This provides the opportunity for students to obtain the best possible clinical experience and correct deficiencies before the clerkship ends. This tool also provides the program with feedback regarding clerkship quality. This allows for identification of deficiency areas at clerkship sites and early intervention should it be necessary.

ROTATION:

1- FM 2- Med 3- Ob/Gyn 4- Surg 5- EM 6- Psych 7- Peds 8-Elective:

ROTATION NUMBER: 12 3 4 5 6 7 8 ROTATION SITE:

Please rate the following learning experiences as appropriate to your rotation 5= superior 4= very good 3= good. 2= fair. 1= poor. N/A = Not Applicable

Student Self-Assessment: How would you rate the following items:

1) Your ability to acclimate and acculturate to the clinical team? 2) Your professional behavior and attendance? 3) Your ability to perform histories and administer physicalexaminations? 4) Your ability to formulate a differentialdiagnosis? 5) Your ability to formulate and implement a managementplan? 6) Your oral presentations? 7) Your ability to perform clinical procedures?

Clerkship Site Analysis: How would you rate the following items:

1) Appropriateness of supervision (i.e., is the supervisor adequately supervising patient encounters)? 2) Opportunity to perform history and physical examinations? 3) Opportunity to formulate differential diagnosis and managementplans? 4) Opportunity to perform oral presentations? 5) Opportunity to perform clinical procedures? 6) Ability for this clerkship to meet the stated learning objectives?

COMMENTS:

Student Clinical Site & Preceptor Evaluation

Your feedback regarding your clinical experience is very important to the ongoing assessment and improvement process of the Hofstra Physician Assistant Studies Program. Please complete this confidential evaluation of your clinical site and preceptor on Exxat. We also ask that you provide detailed recommendations, using professional language, on how this experience may be improved. Your input is voluntary and appreciated. Your comments will not in any manner, affect your final clerkship grade.

ROTATION:

1- FM 2- Med 3- Ob/Gyn 4- Surg 5- EM 6- Psych 7- Peds 8-Elective:

ROTATION NUMBER: 12 3 4 5 6 7 8 ROTATION SITES:

Please rate the following learning experiences as appropriate to your rotation as: 5= Strongly Agree 4= Agree 3= Neither Agreenor Disagree 2= Disagree 1= Strongly Disagree N/A = Not Applicable to this clinical rotation

Clinical Rotation Site Evaluation

1. The clinical site provided students with an orientation to thesetting 2. The clinical site provided students with the opportunity to collaborate with/become a part of the medical team 3. The clinical site made students feel comfortable approaching staff with questions __ 4. The clinical site provided students with opportunities to interview and examine patient __ 5. The clinical site provided students with the ability to observe, learn, assist and/or perform clinical procedures 6. The clinical rotation, in conjunction with self-study, enabled the students to achieve stated learning objectives

Preceptor Evaluation

1. The preceptor provides students with the opportunity to formulate differential diagnoses and management plans 2. The preceptor provides students with the ability to observe, learn, assist and/or perform clinical procedures 3. The preceptor provides adequate supervision for thestudents 4. The preceptor provides students with the opportunity to present patients tothem 5. The preceptor provides guidance regarding student’s clinical notewriting

6. The preceptor gives the students feedback regarding their performance throughout the clinical rotation 7. The preceptor encouraged the student to ask question and wasapproachable

Site/Preceptor Evaluation

1. Would you recommend this site to other students? a.Yes b.No c.Unsure d.Why or why not (please be detailed and use professional language)

2. Would you recommend this preceptor to other students? a.Yes b.No c.Unsure d.Why or why not? (Please be detailed and use professionallanguage)

STUDENT/PRECEPTOR REVIEW OF CLINICAL OBJECTIVES FORM

Student

(NAME) at Hofstra University Physician

Assistant Program has provided me the learning objectives for this rotation. We discussed

in detail the expectations involved in successfully completing this rotation.

Preceptor

Student

Date

Hofstra University Physician Assistant Program Exposure Incident Investigation Form

Date of Report: __________________________ Time of Report: _____________ Date of Incident _________________________ Time of Incident ____________

Name and Hofstra ID# of Student(s) involved in incident:

Name of Preceptor/Instructor at time of incident:

Location of potential exposure (classroom, Bioskills, or clinical clerkship):

If clinical clerkship, include specific site, discipline, and rotation number (ex: Woodhull, IM, rotation #4)

Exposure occurred as part of (check all that apply):

Supervised laboratory assignment Patient care provided during clinical experience hours Northwell Bioskills Lab Other _______________________________________________________

Potentially Infectious Materials Involved: Type of body fluids, route, and source of exposure (ie. Needle stick, contact with open wound, etc)

Circumstance (Task being performed, where, how, and severity of the exposure):

How incident was caused? (Accident, equipment malfunction. if a device was being used include type and brand of device, whether or not it was a safety device, and when in the course of handling the device, the incident occurred):

Personal protective equipment being used: (gloves, gown, etc.):

Actions taken (decontamination, clean-up, immediate referral, reporting, etc.):

Recommendations for avoiding repetition:

If at Northwell Bioskills Lab, a copy of the Anatomy Gifts Registry specimen data sheet is attached? YES NO Student has the Post-Exposure Evaluation and Follow-Up Checklist? circle one: YES NO

Student Signature _____________________________________________________________________

Name and Title of Investigator (Academic Coordinator or Clinical Coordinator): Print and Sign _____________________________________________________________________

Hofstra University Department of Physician Assistant Studies Post-Exposure Evaluation and Follow-Up Checklist

Date of Report: __________________________

Name and Hofstra ID# of Student(s) involved in incident: ____________________________

The following steps must be taken, and information transmitted, in the case of a student’s exposure to Bloodborne Pathogens: Activity Completion Date The Exposure Incident Investigation Form was completed If applicable, source individual’s blood tested, and result given to exposed student.

Consent was not obtained

Exposed Student’s Signature

If applicable, exposed student’s blood collected and tested. If refused, student must sign below.

Exposed Student’s Signature

If refused to see health care professional, then exposed student must sign below (_________________________________)

Exposed Student’s Signature

Name of Hofstra Student Health Services Provider – Print and Signature:

__________________________________________________________ Date: _____________

2021-2022 CLINICAL YEAR HANDBOOK AGREEMENT FORM

September 2021 Edition

The 2021-2022 Physician Assistant Studies Program Clinical Handbook outlines school-wide and program-specific policies and regulations for Physician Assistant Program students in the clinical phase of the program. The clinical handbook is to be used in conjunction with the student handbook and does not supersede the student handbook. If the student is in doubt about the intent or content of any of the material in this handbook, it is his or her responsibility to initiate a discussion with their faculty advisor or the clinical coordinator.

I have read and understand the policies, rules and regulations as outlined within the Hofstra University Physician Assistant Program Clinical Year Handbook and agree, without reluctance, to abide by them.

NAME (Signature):

NAME (Print):

DATE:

FAMILY MEDICINE CLERKSHIP: HEALTH PROMOTION PROJECT

Name: Date:

The main goal of this health promotion project is to enable patients to increase control over and improve their own health. As healthcare providers, it is our responsibility to promote healthy lifestyles, along with identifying high risk patients who can develop complications from their various chronic illnesses or lifestyle risk factors. The objectives of this project are to inform patients about the prevention of a specific disease states and evaluate the effectiveness of their efforts.

Ask the patient the following questions and record and reassess the results. Please attach a current article (<5 years old) that discusses health promotion issues that relates to one of your patient’s illness(es). The assignment must be typed.

1. Identify and list this patient’s chronic illnesses and any lifestyle risk factors. Make sureto include the age, sex, and race of your patient.

2. What specific recommendations or actions did you take to enable patient selfmanagement, disease prevention and health promotion?

3. Has your patient been receiving continuous health screening from visited facility? If so, when and what was done? If no, what health care maintenance or health screening is this patientdue for?

5. Please read your article (<5 years) that discusses one health promotion issue that relates to your patient’s illness(es). Please attach a one-page, typed, double spaced paper summarizing the article and discussing opinions regarding the article.

HEALTH PROMOTION PROJECT GRADE FORM

Student Name Rotation Number

Date

Content • Identified and listed patient’s chronic illnesses and lifestyle risk factors. • Describes specific recommendations or actions taken to enable patient selfmanagement, disease prevention and health promotion. • Discusses whether patient is receiving continuous health screening from visited facility. If so, elaborates. • Patient is reassessed. Discusses changes made or attempted • States, expands, and supports main points. • Exercises proper composition skills.

Research Article _________(45%)

• Research article current (<5 years) • Research article is appropriate for topic • Paper summarizes article • Opinions regarding the article arediscussed • Exercises proper composition skills

(45%)

Professionalism • Submitted materials on time in a professional manner • Student was engaged his/her audience and had good command of topic (10%)

Final Score: (100%)

Faculty:

END OF ROTATION GRADE FORM

Name:

Site:

Final Grade:

Rotation: 1 2 3 4 5 6 7 8 Rotation Type: FM MED OB/GYN SURG EM PSYCH PEDS ELECT:

The components for Psychiatry, Pediatrics, Surgery and OB/GYN clerkships are the following:

Submitted Notes

End of Rotation Examination Summary

Preceptor Evaluation

Clinical Documentation and 3 Pharm Cards

Interesting Case Assignment

Procedure Logging Requirements

Clerkship Patient Encounters Requirements

Completion of Call Back Day Activities

Developmental Disabilities Curriculum Requirements

Quality Assurance/Performance Improvement

The components for Family Medicine, Internal Medicine and Emergency Medicine clerkships are the following:

Submitted Notes

End of Rotation Examination Summary

Preceptor Evaluation

Clinical Documentation and 3 Pharm Cards

Sim Man or Virtual Cases

Interesting Case Assignment or Health Promotion Project

Procedure Logging Requirements

Clerkship Patient Encounters Requirements

Completion of Call Back Day Activities

Developmental Disabilities Curriculum Requirements

Preceptor Evaluation

Elective Interesting Case Presentation

Procedure Logging Requirements

Clerkship Patient Encounters Requirements

Completion of Call Back Day Activities

Developmental Disabilities Curriculum Requirements

Quality Assurance/Performance Improvement

OVERALL GRADE: FACULTY SIGNATURE: Submitted Notes

DATE:

Medical Interview

• Conveys understanding and empathy for patient • Obtains all pertinentinformation • Follows an organizedformat • Obtains history in a reasonable time

Physical Examination

• Explains procedure to patient beforeexam • Performs examination in an orderlysequence • Demonstrates respect forpatient • Performs appropriate and accurateexam

Oral Case Presentation

• Clear, organized, concisepresentation • Includes all major activecomplaints/problems

Patient Record

• Written materials are neat, legible, andappropriate • Accurately and adequately documents patientencounters • Electronic record, when utilized, is accurate andorganized

Utilization & Interpretation of Diagnostic Tests

• Demonstrates sound knowledge oftests • Orders appropriate test(s) for working differentialdiagnosis • Uses appropriate discretion inordering • Demonstrates the ability to interpret diagnostictests • Demonstrate care that is effective, safe, equitable, and high quality

Technical Skills/Clinical Procedures

• Performs procedures safely and at appropriate skilllevel • Understands indication(s) forprocedure(s) • Explains and attains consent of patient before startingprocedure

Problem Solving/Clinical Thinking

• Synthesizes and analyzes clinical datacorrectly • Determines major active problem accurately and in a timelyfashion • Determines abnormal fromnormal • Utilizes and evidence-based approach tomedicine

Fund of Knowledge and Application of Concepts

• Demonstrates application of basic and clinical sciences to patientcare • Demonstrates evidence of outside reading and studies duringrotation • Ability to apply knowledge of biomedical and psychosocialprinciples • Uses information technology to support the application ofknowledge

Assessment/Differential Diagnoses

• Formulates and justifies differentialdiagnoses • Determine the etiologies, risk factors, and epidemiology for medicalconditions • Identify the signs and symptoms of medicalconditions

Ability to Formulate and Implement a Follow-up and Management Plan

• Designs an effective and appropriate careplan • Selects appropriate consultations and referrals • Demonstrates an appropriate understanding of pharmacologicplan • Implements plan consistently andappropriately • Arranges for patientfollow-up • Performs patient education at appropriatelevel • Uses counseling and patient education skillseffectively

Relating to Colleagues

• Ability to work collaboratively in inter-professionalteams

Relating to Patients

• Communicates effectively and appropriately withpatients • Demonstrates respect and empathy forpatients

Understanding of PA Role

• Demonstrates understanding for medicalconditions and situations that require an attending physician or consultation • Understands the PA profession and the role of the PA as a team member

Reliability and Dependability

• Assumes appropriate level ofresponsibility • Completes tasks thoroughly and in a timelyfashion

Self-Confidence

• Demonstrates confidence in clinical competence to patient, peers, andpreceptor

Attitude Toward Learning

• Demonstrates independent learning effort; undertakes supplemental readings; is inquisitive, insightful, and enthusiastic; attends conferences and lectures; and demonstrates knowledge of assignedreadings

Professionalism

• Exhibits culturalawareness • Maintains professional relationship with patients, staff, andpreceptor • Demonstrates ethical behavior and attitude in accordance with AAPA’s Guidelines for Ethical

Conduct for the Physician AssistantProfession • Respect’s patient privacy andconfidentiality • Demonstrates a positive response to constructivecriticism • Dresses appropriately for professionalrole • Maintains clean and kemptappearance

Student Preparedness for Clinical Clerkship

• Student was well prepared to transition into clinicalclerkship