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The University Of Sheffield

PHASE 3A MBChB 2013

CLINICAL ATTACHMENT ASSESSMENT & FEEDBACK PROFORMAS

THE ASSESSMENT PROFORMAS SHOULD BE RETURNED TO THE FOLLOWING

PLEASE TAKE A COPY OF EACH COMPLETED FORM FOR YOUR RECORDS

Womens Health

Gill Burkinshaw Section of Reproductive and Developmental Medicine Jessop Wing Royal Hallamshire Hospital Tree Root Walk Sheffield Joanne OLeary Academic Unit of Child Health Stephenson Wing Sheffield Childrens Hospital Western Bank Sheffield Sarah Turvey Academic Clinical Psychiatry The Longley Centre Northern General Hospital Norwood Grange Drive Sheffield S5 7JT Diane Allen Institute of General Practice and Primary Care Sam Fox House Northern General Hospital Sheffield Jacquie Harrison/Paula Hutchinson School of Medicine Beech Hill Road Sheffield S10 2RX

Child Health

Psychiatry

Community & Public Health

Medicine for Older People Neurology Two Week SSC Sexual Medicine 6 Week SSC

CLINICAL ATTACHMENT ASSESSMENT AND FEEDBACK PROFORMA: Phase 3a


To be completed by student: Student Name: _______________________________________________________ Module: CHILD HEALTH DATES____________________

Registration No______________________________ Supervisors name: ___________________________ To be completed by the student

Hospital:___________________________________________

To be completed by supervisor/deputy: Please give feedback on their overall clinical performance (both formatively and summatively assessed). Professional Behaviours should be considered separately.

Cases Seen (List the cases seen during this attachment)

Feedback 1) Overall clinical performance (, history taking, clinical examination, presentation and discussion of patients, including formative assessments)

2) Confirmation of satisfactory completion of work-place based assessments


Mini CEX (1) [Y] [N] (2) [Y] [N] Observed Long Case [Y] [N]

3) Areas for Further Development

4) Professional Behaviour [Maintains an ethical approach. Adequate attendance and timekeeping; Understands the rules governing consent. Displays positive professional behaviours].

5) Communication skills with patients and staff

The student has successfully completed this attachment


Supervisor Signature___________________________________________ Student Signature______________________________________________

Yes / No

Supervisors Address__________________________________ Date: _____________

PLEASE RETURN THIS FORM TO JOANNE OLEARY ACADEMIC UNIT OF CHILD HEALTH STEPHENSON WING, CHILDRENS HOSPITAL, WESTERN BANK, SHEFFIELD

CLINICAL ATTACHMENT ASSESSMENT AND FEEDBACK PROFORMA: Phase 3a


To be completed by student: Student Name: __________________________________________________________ Module: WOMENS HEALTH DATES____________________

Registration No_______________________________ Supervisors name: ___________________________ To be completed by the student

Hospital:_______________________________________________

To be completed by supervisor/deputy: Please give feedback on their overall clinical performance (both formatively and summatively assessed). Professional Behaviours should be considered separately.

Cases Seen (List the cases seen during this attachment)

Feedback 1) Overall clinical performance (, history taking, clinical examination, presentation and discussion of patients, including formative assessments)

2) Confirmation of satisfactory completion of work-place based assessments


Mini CEX (1) [Y] [N] (2) [Y] [N] Observed Long Case [Y] [N]

3) Areas for Further Development

4) Professional Behaviour [Maintains an ethical approach. Adequate attendance and timekeeping; Understands the rules governing consent. Displays positive professional behaviours].

5) Communication skills with patients and staff

The student has successfully completed this attachment


Supervisor Signature___________________________________________ Student Signature______________________________________________

Yes / No

Supervisors Address__________________________________ Date: _____________

PLEASE RETURN THIS FORM TO GILL BURKINSHAW ACADEMIC UNIT OF REPRODUCTIVE & DEVELOPMENTAL MEDICINE, JESSOP WING, TREE ROOT WALK SHEFFIELD

CLINICAL ATTACHMENT ASSESSMENT AND FEEDBACK PROFORMA: Phase 3a


To be completed by student: Student Name: __________________________________________ DATES____________ Module: COMMUNITY & PUBLIC HEALTH GP TUTOR GP Practice:__________________________________

Registration No_______________________________ Supervisors name: ___________________________ To be completed by the student

To be completed by supervisor/deputy: Please give feedback on their overall clinical performance (both formatively and summatively assessed). Professional Behaviours should be considered separately.

Cases Seen (List the cases seen during this attachment)

Feedback 1) Overall clinical performance (, history taking, clinical examination, presentation and discussion of patients, including formative assessments)

2) Confirmation of satisfactory completion of work-place based assessments


Mini CEX (1) [Y] [N] (2) [Y] [N]

3) Areas for Further Development

4) Professional Behaviour [Maintains an ethical approach. Adequate attendance and timekeeping; Understands the rules governing consent. Displays positive professional behaviours].

5) Communication skills with patients and staff

The student has successfully completed this attachment


Supervisor Signature___________________________________________ Student Signature______________________________________________

Yes / No

Supervisors Address__________________________________ Date: _____________

PLEASE RETURN THIS FORM TO DIANE ALLEN ACADEMIC UNIT OF PRIMARY MEDICAL CARE, SAM FOX HOUSE, NORTHERN GENERAL HOSPITAL, HERRIES ROAD SHEFFIELD

CLINICAL ATTACHMENT ASSESSMENT AND FEEDBACK PROFORMA: Phase 3a


To be completed by student: Student Name: _____________________________________ DATES____________

Registration No_______________________________ Supervisors name: ___________________________ To be completed by the student

Module: COMMUNITY & PUBLIC HEALTH SMALL GROUP GP Practice: (delete)__________________________________

Cases discussed (List the cases key discussed during this attachment)

To be completed by supervisor/deputy: Please give feedback on their overall clinical performance (both formatively and summatively assessed). Professional Behaviour(s) deleted should be considered separately.

Feedback 1) Overall (clinical) performance (presentation and discussion of patients, including formative assessments, preparation for ILA topics etc)

2) Confirmation of satisfactory completion of work-place based assessments


Mini CEX (1) [Y] [N] (2) [Y] [N] N/A

3) Areas for Further Development

4) Professional Behaviour [Maintains an ethical approach. Adequate attendance and timekeeping; Understands the rules governing consent. Displays positive professional behaviours].

5) Communication skills with tutors and peers

The student has successfully completed this attachment


Supervisor Signature___________________________________________ Student Signature______________________________________________

Yes / No

Supervisors Address__________________________________ Date: _____________

PLEASE RETURN THIS FORM TO

DIANE ALLEN ACADEMIC UNIT OF PRIMARY MEDICAL CARE, SAM FOX HOUSE, NORTHERN GENERAL HOSPITAL, HERRIES ROAD SHEFFIELD

CLINICAL ATTACHMENT ASSESSMENT AND FEEDBACK PROFORMA: Phase 3a


To be completed by student: Student Name: ____________________________________________________ Module: PSYCHIATRY DATES____________________

Registration No_______________________________ Supervisors name: ___________________________ To be completed by the student

Hospital:_________________________________________

To be completed by supervisor/deputy: Please give feedback on their overall clinical performance (both formatively and summatively assessed). Professional Behaviours should be considered separately.

Cases Seen (List the cases seen during this attachment)

Feedback 1) Overall clinical performance (, history taking, clinical examination, presentation and discussion of patients, including formative assessments)

2) Confirmation of satisfactory completion of work-place based assessments


Observed Long Case [Y] [N]

3) Areas for Further Development

4) Professional Behaviour [Maintains an ethical approach. Adequate attendance and timekeeping; Understands the rules governing consent. Displays positive professional behaviours].

5) Communication skills with patients and staff

The student has successfully completed this attachment


Supervisor Signature___________________________________________ Student Signature______________________________________________

Yes / No

Supervisors Address__________________________________ Date: _____________

PLEASE RETURN THIS FORM TO SARAH TURVEY ACADEMIC CLINICAL PSYCHIATRY, THE LONGLEY CENTRE, NORTHERN GENERAL HOSPITAL, HERRIES ROAD SHEFFIELD

CLINICAL ATTACHMENT ASSESSMENT AND FEEDBACK PROFORMA: Phase 3a


To be completed by student: Student Name: __________________________________________________ Module: NEUROLOGY DATES__________________ GROUP :______________________________________

Registration No_______________________________ Supervisors name: ___________________________ To be completed by the student

To be completed by supervisor/deputy: Please give feedback on their overall clinical performance (both formatively and summatively assessed). Professional Behaviours should be considered separately.

Cases Seen (Please tick or add the cases seen during this attachment) Gait / coordination problems (14) Problems with higher cognitive function (15, 31, 33) Coma / brain death (16) Dizziness / vertigo (17) Headaches (18, 20) Blackouts / loss of consciousness (19, 23) Movement disorder / tremor (21) Altered sensation (22) Visual field / cranial nerve disorders (24) Weakness (25) Other (please add details below)

Feedback 1) Presentation of patient on ward round (history taking, clinical examination, presentation and discussion of patients, including formative assessments)

2) Areas for Further Development

3) Communication skills with patients and staff

4) Concerns about professional behaviour [Professional behaviour: Maintains an ethical approach; adequate attendance and timekeeping; understands the rules governing consent; displays positive professional behaviours].

5) Confirmation of satisfactory completion of work-place based assessments


Mini CEX (1) [Y] [N] (2) [Y] [N] Written Case History & examination ) [Y] [N]

The student has successfully completed this attachment


Supervisor Signature___________________________________________ Student Signature______________________________________________

Yes / No

Supervisors Address__________________________________ Date: _____________

PLEASE RETURN THIS FORM TO JACQUIE HARRISON SCHOOL OF MEDICINE, MEDICAL SCHOOL, BEECH HILL ROAD SHEFFIELD

CLINICAL ATTACHMENT ASSESSMENT AND FEEDBACK PROFORMA: Phase 3a


To be completed by student: Student Name: ________________________________________ DATES ______________ Module: MEDICINE FOR OLDER PEOPLE

Registration No_______________________________

Supervisors name: ___________________________ Hospital/GROUP:_______________________________________________ To be completed by the student To be completed by supervisor/deputy: Please give feedback on their overall clinical performance (both formatively and summatively assessed). Professional Behaviours should be considered separately.

Cases Seen (List the cases seen during this attachment)

Feedback 1) Overall clinical performance (, history taking, clinical examination, presentation and discussion of patients, including formative assessments)

2) Confirmation of satisfactory completion of work-place based assessments


Case Study [Y] [N]

3) Areas for Further Development

4) Professional Behaviour [Maintains an ethical approach. Adequate attendance and timekeeping; Understands the rules governing consent. Displays positive professional behaviours].

5) Communication skills with patients and staff

The student has successfully completed this attachment


Supervisor Signature___________________________________________ Student Signature______________________________________________

Yes / No

Supervisors Address__________________________________ Date: _____________

PLEASE RETURN THIS FORM TO JACQUIE HARRISON SCHOOL OF MEDICINE, MEDICAL SCHOOL, BEECH HILL ROAD SHEFFIELD

6-week SSC ASSESSMENT PROFORMA: Phase 3a


To be completed by student: Student name_______________________________________________________________________________ Student Registration No________________________ Group _____________ Dates of SSC______________________________________

Supervisor/marker name________________________________________________________________________________________________ Supervisor/marker address_____________________________________________________________________________________________

All Sections to be completed by the Supervisor/Marker


Please assess the student on the following criteria which are defined in more detail in the Schools Outcome Objectives and those learning outcomes agreed for this SSC. Professional Behaviours should be considered separately from the generic and specific skills assessments.

PLEASE CIRCLE THE APPROPRIATE JUDGEMENT


Excellent Good Satisfactory Borderline Unsatisfactory

Generic Graduate Skills


[Includes skills in written communication, information gathering, organisation and selfmanagement]. Feedback for all grades please

(Continue overleaf) Excellent Good Satisfactory Borderline Unsatisfactory

SSC Specific Skills


These are defined by the student and supervisor and should indicate clear aims, learning goals and appropriate assessment Feedback for all grades please

(Continue overleaf) Excellent Good Satisfactory Borderline Unsatisfactory

IT Skills
i [Word processed report, poster & abstract; presentation & abstract or other agreed assessment]. Feedback for all grades please

(Continue overleaf) Excellent Good Satisfactory Borderline Unsatisfactory

Overall Competence
Feedback for all grades please

Overall performance on generic and specific skills for stage of training


(Continue overleaf)

Excellent

Good

Satisfactory

Borderline

Unsatisfactory

Professional Behaviours
[Includes ensuring an ethical approach, avoiding plagiarism, & completion on time and as requested]. Feedback for all grades please

(Continue overleaf)) Signature of Supervisor/marker____________________________________________________ Date___________________________________

PLEASE RETURN THIS FORM TO JACQUIE HARRISON SCHOOL OF MEDICINE, MEDICAL SCHOOL, BEECH HILL ROAD SHEFFIELD

The Sheffield Core Curriculum Outcome Objectives for Undergraduate Medicine

Phase 3a 6-Week SSC


Generic Graduate Skills GS1 Adopts the principles of reflective practice and life-long learning GS2 Knows the limits of professional competence GS3 Presents information clearly in all formats GS4 Is an effective teacher/mentor GS5 Capable of self-management GS6 Applies research principles and audit and studies topics in depth GS7 Can deal with uncertainty GS8 Manages information retrieval, presentation and manipulation electronically IS1 Can establish, build and maintain proper partnerships with patients, their family/friends/carers IS2 Communicates effectively Works effectively as a member of a multidisciplinary team

Interpersonal Skills

IS3

Clinical Skills

IS4 Deals sensitively with patients, their family/friends/carers IS5 Identifies potential danger for self and others and takes appropriate action to limit impact CS1 Contributes to cure of illness, recovery from sickness and the easing of suffering and discomfort in encounters with patients CS2 Participates in health promotion and in prevention of disease and disability in encounters with patients CS3 Gathers relevant patient history information systematically either from patient or third party Conducts complete mental state examination or selects appropriate components in a systematic and directed fashion CS5 Conducts complete physical examination or selects appropriate components in a systematic and directed fashion CS6 Makes accurate assessment of patient's problems & formulates differential diagnosis CS7 Selects & initiates appropriate investigations CS8 Interprets and evaluates data from history, physical examination and other findings to formulate diagnosis CS9 Formulates and implements management plan and monitors its effectiveness PS1 Ensures optimum patient comfort and privacy PS2 Prepares patient for, explains & conducts technical and practical procedures effectively PS3 Ensures patient consent is obtained in all aspects of investigation, treatment and management PS4 Can access relevant information and record information accurately PS5 Makes thorough and accurate observations, measurements and calculations PS6 Recognises, identifies and can describe abnormalities and symptoms PS7 Demonstrates effective decision making PS8 Manages life-threatening conditions PB1 Adopts a questioning approach to own work and that of others PB2 Works within limits of own knowledge and experience PB3 Maintains patient confidentiality PB4 Is responsive to changes in health care, policy and current science PB5 Maintains an ethical approach PB6 Complies with legal responsibilities and requirements and guidelines of regulatory bodies and the NHS PB7 Demonstrates respect for the role and function of all those involved in patient care PB8 Demonstrates a patient centred approach CS4

Practical Skills

Professional Behaviours

PB9 Recognises and takes advantage of opportunities to teach PB10 Fulfils professional responsibilities in contexts inside & outside work SSC Specific Outcomes Able to identify own learning needs and negotiate those with supervisor Fulfils learning needs Fulfils agreed assessment Produces a word-processed document which is formatted appropriately and uploaded to the e-portfolio

1-week SSC ASSESSMENT PROFORMA: Psychiatry, Neurology, Medicine for Older People Phase 3a
To be completed by student: Student Registration No________________________ Group _____________ Dates of SSC______________________________________

Supervisor/marker name________________________________________________________________________________________________ Supervisor/marker address_____________________________________________________________________________________________

All sections to be completed by the Supervisor/Marker


Please assess the student on the following criteria which are defined in more detail in the Schools Outcome Objectives and those learning outcomes agreed for this SSC. Professional Behaviours should be considered separately from the generic and specific skills assessments.

PLEASE CIRCLE THE APPROPRIATE JUDGEMENT


Excellent Good Satisfactory Borderline Unsatisfactory

Generic Graduate Skills


[Includes skills in written communication, information gathering, organisation and selfmanagement]. Feedback for all grades please

(Continue overleaf) Excellent Good Satisfactory Borderline Unsatisfactory

SSC Specific Skills


[Understanding of the subject, able to write a structured essay with reference to the literature. Critical analysis of the literature]. Feedback for all grades please

(Continue overleaf) Excellent Good Satisfactory Borderline Unsatisfactory

IT Skills
i [Word processed report, formatted appropriately]. Feedback for all grades please

(Continue overleaf) Excellent Good Satisfactory Borderline Unsatisfactory

Overall Competence
Feedback for all grades please

Overall performance on generic and specific skills for stage of training


(Continue overleaf)

Satisfactory

Borderline

Unsatisfactory

Professional Behaviours
[Includes ensuring an ethical approach, avoiding plagiarism, & completion on time and as requested]. Feedback for all grades please

(Continue overleaf)) Signature of Supervisor/marker____________________________________________________ Date___________________________________

PLEASE RETURN THIS FORM TO JACQUIE HARRISON SCHOOL OF MEDICINE, MEDICAL SCHOOL, BEECH HILL ROAD SHEFFIELD

The Sheffield Core Curriculum Outcome Objectives for Undergraduate Medicine

Psychiatry, Neurology and Care of Elderly People (Phase 3a)

Outcomes in bold italics relate to this specific SSC


Generic Graduate Skills GS1 GS2 GS3 GS4 GS5 GS6 GS7 GS8 Interpersonal Skills IS1 IS2 IS3 IS4 Adopts the principles of reflective practice and life-long learning Knows the limits of professional competence Presents information clearly in all formats Is an effective teacher/mentor Capable of self-management Applies research principles and audit and studies topics in depth Can deal with uncertainty Manages information retrieval, presentation and manipulation electronically Can establish, build and maintain proper partnerships with patients, their family/friends/carers Communicates effectively Works effectively as a member of a multidisciplinary team Deals sensitively with patients, their family/friends/carers

IS5 Identifies potential danger for self and others and takes appropriate action to limit impact Clinical Skills CS1 and Contributes to cure of illness, recovery from sickness and the easing of suffering discomfort in encounters with patients

CS2 Participates in health promotion and in prevention of disease and disability in encounters with patients CS3 Gathers relevant patient history information systematically either from patient or third party Conducts complete mental state examination or selects appropriate components in a systematic and directed fashion CS5 Conducts complete physical examination or selects appropriate components in a systematic and directed fashion CS6 Makes accurate assessment of patient's problems & formulates differential diagnosis CS7 Selects & initiates appropriate investigations CS8 Interprets and evaluates data from history, physical examination and other findings to formulate diagnosis CS9 Formulates and implements management plan and monitors its effectiveness Practical Skills PS1 Ensures optimum patient comfort and privacy PS2 Prepares patient for, explains & conducts technical and practical procedures effectively PS3 Ensures patient consent is obtained in all aspects of investigation, treatment and management PS4 Can access relevant information and record information accurately PS5 Makes thorough and accurate observations, measurements and calculations PS6 Recognises, identifies and can describe abnormalities and symptoms PS7 Demonstrates effective decision making PS8 Manages life-threatening conditions PB1 Adopts a questioning approach to own work and that of others PB2 Works within limits of own knowledge and experience PB3 Maintains patient confidentiality PB4 Is responsive to changes in health care, policy and current science PB5 Maintains an ethical approach PB6 Complies with legal responsibilities and requirements and guidelines of regulatory bodies and the NHS PB7 Demonstrates respect for the role and function of all those involved in patient care PB8 Demonstrates a patient centred approach PB9 Recognises and takes advantage of opportunities to teach PB10 Fulfils professional responsibilities in contexts inside & outside work CS4

Professional Behaviours

SSC Specific Outcomes

Understands the subject Able to write in the style of a scientific paper Can word-process a report which is formatted appropriately and uploaded to the eportfolio

CLINICAL ATTACHMENT ASSESSMENT AND FEEDBACK PROFORMA: Phase 3a


To be completed by student: Student Name: ___________________________________________________ Module: SEXUAL MEDICINE DATES ______________ Hospital:________________________________________

Registration No_______________________________ Supervisors name: ___________________________

PLEASE CIRCLE THE APPROPRIATE JUDGEMENT

Attendance
I confirm that the above named student has attended both the Lectures and Seminar for Psychosexual Medicine

Satisfactory Please provide FEEDBACK for all grades awarded

Borderline

Unsatisfactory

(Continue overleaf as necessary) Signature of Student Date

Signature of Supervisor

Date

PLEASE RETURN THIS FORM TO JACQUIE HARRISON SCHOOL OF MEDICINE, MEDICAL SCHOOL, BEECH HILL ROAD SHEFFIELD

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