Preceptor Evaluation of PA Student
|Clerkship No. (1-9)||____________________|
|Preceptor’s Name and Title||____________________|
|Medical Discipline Completed||____________________|
|Supervising Physician (as identified by PA Studies Program)||____________________|
|Date of Clerkship||____________________|
Please assess the PA student in each of the categories listed below by rating the student’s performance:
4= Exceeds expectations 3= Meets expectations 1= Does not meet expectations N/A= Not observed or not applicable
|A. Medical interview||A. ||1. Relating to Colleagues||1. |
|B. Physical examination||B. ||2. Relating to Patients||2. |
|C. Oral case presentation||C. ||3. Understanding of PA role and recognition of limitations||3. |
|D. Written patient record||D. ||4. Self-confidence||4. |
|E. Appropriate laboratory tests knowledge & utilization||E. ||5. Reliability, Dependability & attendance||5. |
|F. Clinical procedures||F. ||6. Professionalism||6. |
|G. Clinical reasoning and problem|
|7. Attitude||7. |
|H. Factual knowledge & concepts||H.||8. Appearance||8. |
|I. Assessment and differential|
|J. Ability to form and implement a|
|J. ||Number of Absences|| __ |
Do you have any reservations about the clinical competency of this student?
Do you have reservations about the professional behavior of this student?
Do you desire a phone call from a clinical coordinator regarding this student?
Preceptor’s signature Date
Student’s signature after review ________ _ Date ___
FAX: 843-792-9172 or 792-0506 E-mail: firstname.lastname@example.org Phone: 843-792-1913
Mail: PA Division (B-103), 151-B Rutledge Ave. (MSC 962), Charleston, SC, 29425.