14 DHYG 425 Community Dental Health II: Student Rotation Performance Evaluation
Danette Lindeman
LAKE WASHINGTON INSTITUTE OF TECHNOLOGY
STUDENT ROTATION PERFORMANCE EVALUATION
| STUDENT NAME: | Appointment: Chair Time:
Date ________________ Pt #1 In ________ Out ________ Pt #2 In ________ Out ________ Pt #3 In ________ Out ________ Pt #4 In ________ Out ________
Total Patient Contact Time: Hrs _____ / Min. _____ |
||||
| QTR: (highlight one) | SU2 | F2 | W2 | SP2 | |
| SITE: (highlight one) | OB | CHC-E
CHC-L |
SKCC | ||
| SUPERVISOR:
|
| PATIENT #1 | ||||||
| Special Needs: (circle below) Age: (circle below) AAP Class______ | ||||||
| MC | PD | MD | Pedo (1-12) | Adolescent (13-17) | Adult (18-59) | Gerio (60+) |
| Procedure(s) Completed: | Supervisor Initials | |||||
| PATIENT #2 | ||||||
| Special Needs: (circle below) Age: (circle below) AAP Class______ | ||||||
| MC | PD | MD | Pedo (1-12) | Adolescent (13-17) | Adult (18-59) | Gerio (60+) |
| Procedure(s) Completed: | Supervisor Initials | |||||
| PATIENT #3 | ||||||
| Special Needs: (circle below) Age: (circle below) AAP Class______ | ||||||
| MC | PD | MD | Pedo (1-12) | Adolescent (13-17) | Adult (18-59) | Gerio (60+) |
| Procedure(s) Completed: | Supervisor Initials | |||||
| PATIENT #4 | ||||||
| Special Needs: (circle below) Age: (circle below) AAP Class______ | ||||||
| MC | PD | MD | Pedo (1-12) | Adolescent (13-17) | Adult (18-59) | Gerio (60+) |
| Procedure(s) Completed: | Supervisor Initials | |||||
| To be completed by both extern site supervisor and student: | |||
| Self
Evaluation |
Supervisor
Evaluation |
Supervisor Comments | |
| ATTENDANCE | A I S | A I S | |
| RAPPORT WITH PATIENTS | A I S | A I S | |
| RAPPORT WITH SUPERVISOR(S) | A I S | A I S | |
| PROFESSIONALISM:
Conduct/Behavior |
A I S | A I S | |
| Appearance | A I S | A I S | |
| Clinic Responsibilities | A I S | A I S | |
| GENERAL CLINIC
SKILLS |
A I S | A I S |
| The following criteria will be used to indicate student performance: | |||
| ATTENDANCE | |||
| A | Student arrives early or at the designated start time as indicated by the individual facility. Student remains in the facility until all procedures are complete for the day. | ||
| I | Student arrives within 10 minutes of the designated start time as indicated by the individual facility. Student leaves the facility prior to the end of the clinical session or asks to be dismissed early. | ||
| S | Student arrives over 10 minutes after the designated start time or fails to show up for his/her scheduled rotation. Student leaves the facility prior to the end of the clinical session and fails to inform the site supervisor. | ||
| RAPPORT WITH PATIENTS | |||
| A | Communicates effectively with patients from diverse backgrounds or with special needs. Student is respectful and empathetic during patient interaction. Puts the needs patients above his/her requirements. | ||
| I | Communication skills are satisfactory. Student will still put the needs of the patient first but may need minor improvements in his/her ability to relate to patients. | ||
| S | Student lacks effective communication skills and/or the ability to relate to patients. Student does not put the needs of the patient above his/her own. | ||
| RAPPORT WITH SUPERVISORS | |||
| A | Student is open to suggestions, seeks input, and incorporates suggestions. Employs problem-solving techniques with other professionals. Is assertive, proactive, and respectful. | ||
| I | Student demonstrates satisfactory interaction with supervisor(s). Maintains an approachable attitude. | ||
| S | Student exhibits a defensive attitude. Is considered unapproachable, confrontational, or disrespectful. | ||
| CONDUCT/BEHAVIOR | |||
| A | Projects a professional attitude and strong work ethic. Works effectively in a team setting with facility personnel, supervisors, patients, and fellow students. Willingly steps outside of his/her comfort zone and accepts new challenges enthusiastically. | ||
| I | Minor professional attitude or work ethic issues. Student may lack initiative to step out of his/her comfort zone. | ||
| S | Significant professional or work ethic issues. Is unwilling or refuses to step outside of his/her comfort zone or accept new challenges. | ||
| APPEARANCE | |||
| A | Professional appearance; including modest clinical attire “scrubs”, impeccable personal hygiene, and grooming. | ||
| I | Satisfactory attire, personal hygiene, and grooming. | ||
| S | Student fails to adhere to professional standards in dress, personal hygiene, and/or grooming. | ||
| CLINIC RESPONSIBILITIES | |||
| A | Student adheres to all clinical extern site policies and procedures: including management of paperwork, following instructions, preparedness for clinic, and setup/clean up procedures/ | ||
| I | Student needs improvement or requires assistance in following clinical extern site policies and procedures. | ||
| S | Student fails to adhere to clinical extern site policies and procedures. | ||
| GENERAL CLINICAL SKILLS | |||
| A | Meets or exceeds expectations of appropriate patient care. Modifies treatment techniques based on the individual needs of the patient. Demonstrates appropriate decision-making skills. Student is organized, stays on schedule, and demonstrates exceptional time management skills. | ||
| I | Patient care is satisfactory. Student can still modify treatment technique based on individual need but may require assistance. Makes appropriate decisions with minimal assistance. Student has minor issues with organization and/or time management. | ||
| S | Patient care falls below expectations. Student requires major assistance with decision-making. Student has major issues with organization and/or time management. | ||
| Patient Categories: | |||
| MEDICALLY COMPROMISED
MC |
PHYSICALLY DISABLED
PD |
MENTALLY DISABLED
MD |
|
| Any patient that requires alterations to care due to a medical condition. For example:
· A patient who is hypoglycemic and needs a sugar source.
|
Any patient with physical limitations or a disability that requires alterations to care. For example:
|
Patients with altered or diminished mental capacity requiring alterations to care. For example:
· A patient who is anxious or fearful about dental treatment and requires treatment modifications such as nitrous oxide. |
|
