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1 Step 1
GOLDUSMLE MEDICAL STUDENT PERFORMANCE EVALUATION
DOCTOR NUMBER #your full name
CHIEF COMPLAINTyour full name
INTRODUCTION/CLOSURE COMPLETED?
HOW CAN THIS BE IMPROVED? PLEASE SPECIFY EXAMPLESmore details
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EMPATHY/BEDSIDE MANNER/COUNSELING COMPLETED?
HOW CAN THIS BE IMPROVED? PLEASE SPECIFY EXAMPLESmore details
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EYE CONTACT MADE? PROFESSIONALISM DISPLAYED THROUGHOUT ENCOUNTER?
HOW CAN THIS BE IMPROVED? PLEASE SPECIFY EXAMPLESmore details
0 /
HISTORICAL QUESTIONS COMPLETED? ANY MISSING?
WHAT HISTORICAL QUESTIONS WERE MISSING? PLEASE PROVIDE SPECIFIC EXAMPLESmore details
0 /
PHYSICAL EXAM COMPLETED? PLEASE SPECIFY WHICH STEPS WERE MISSED.
HOW CAN THIS BE IMPROVED? PLEASE SPECIFY EXAMPLESmore details
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SPOKEN ENGLISH CLEAR? UNDERSTANDABLE? WHAT WORDS WERE MISPRONOUNCED?
HOW CAN THIS BE IMPROVED? PLEASE SPECIFY EXAMPLESmore details
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MEDICAL TERMINOLOGY USED?GIVE EXAMPLES? DID DOCTOR MAKE IT EASY AND USE LAYMENS TERMS?
HOW CAN THIS BE IMPROVED? PLEASE SPECIFY EXAMPLESmore details
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DIFFERENTIALS CORRECT? WHAT DID DOCTOR GIVE AS IMPRESSION? IF INCORRECT TYPE OUT WHAT IT SHOULD HAVE BEEN, IF NONE GIVEN TYPE "INCOMPLETE" THEN TYPE OUT WHAT IT SHOULD HAVE BEEN.
DIFFERENTIAL DIAGNOSIS 1. IF INCORRECT TYPE CORRECT DIAGNOSIS DIFFERENTIAL DIAGNOSIS 2 IF INCORRECT TYPE CORRECT DIAGNOSISmore details
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DIAGNOSTIC STUDIES/ TESTS GIVEN? IF INCOMPLETE TYPE "INCOMPLETE"
DIAGNOSTIC STUDY 1 IF INCORRECT TYPE CORRECT TEST. DIAGNOSTIC STUDY 2 IF INCORRECT TYPE CORRECT TESTmore details
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WAS ENCOUNTER FINISHED ON TIME? WAS ENCOUNTER ACCEPTABLE? WHAT IS DOCTORS MAIN WEAKNESS?
PLEASE PROVIDE SUGGESTIONS, AND GIVE AN OVERALL STATEMENT ON DOCTORS MAIN WEAKNESS.more details
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SANITIZED HANDS BEFORE ENCOUNTER BEFORE PHYSICAL AND BEFORE LEAVING?
ADDITIONAL COMMENTS OR SUGGESTIONS FOR THIS DOCTOR?more details
0 /
OVERALL PERFORMANCE
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