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TheUniversityOfSheffield

PHASE 3A MBChB

2013

CLINICAL ATTACHMENTASSESSMENT & FEEDBACKPROFORMAS

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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 WingRoyal Hallamshire Hospital

Tree Root Walk

Sheffield

Child Health Joanne OLeary

Academic Unit of Child Health

Stephenson Wing

Sheffield Childrens Hospital

Western Bank

Sheffield

Psychiatry Sarah Turvey

Academic Clinical Psychiatry

The Longley Centre

Northern General Hospital

Norwood Grange Drive

Sheffield

S5 7JT

Community & Public Health Diane Allen

Institute of General Practice and Primary

Care

Sam Fox House

Northern General Hospital

Sheffield

Medicine for Older People

Neurology

Two Week SSC

Sexual Medicine

6 Week SSC

Jacquie Harrison/Paula Hutchinson

School of Medicine

Beech Hill Road

Sheffield

S10 2RX

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CLINICAL ATTACHMENT ASSESSMENT AND FEEDBACK PROFORMA: Phase 3a

To be completed by student: Student Name: _______________________________________________________

Registration No______________________________ Module: CHILD HEALTH DATES____________________

Supervisors name: ___________________________ Hospital:___________________________________________

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

Cases Seen (List the cases seenduring this attachment)

Feedback1) Overall clinical performance (, history taking, clinical examination,presentation and discussion of patients, including formative assessments)

2) Confirmation of satisfactory completion of work-place based assessmentsMini 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 andtimekeeping; Understands the rules governing consent. Displays positive professionalbehaviours].

5) Communication skillswith patients and staff

The student has successfully completed this attachment Yes / NoSupervisor Signature___________________________________________

Student Signature______________________________________________

Supervisors Address__________________________________ Date: _____________PLEASE RETURN THIS FORM TO JOANNE OLEARY ACADEMIC UNIT OF CHILD HEALTH STEPHENSON WING,CHILDRENS HOSPITAL, WESTERN BANK, SHEFFIELD

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To be completed by student: Student Name: __________________________________________________________

Registration No_______________________________ Module: WOMENS HEALTH DATES____________________

Supervisors name: ___________________________ Hospital:_______________________________________________




2) Confirmation of satisfactory completion of work-place based assessmentsMini CEX (1) [Y] [N] (2) [Y] [N] Observed Long Case [Y] [N]






Supervisors Address__________________________________ Date: _____________

PLEASE RETURN THIS FORM TO

GILL BURKINSHAW ACADEMIC UNIT OF REPRODUCTIVE & DEVELOPMENTAL MEDICINE, JESSOP WING,TREE ROOT WALK SHEFFIELD

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To be completed by student: Student Name: __________________________________________ DATES____________

Registration No_______________________________ Module: COMMUNITY & PUBLIC HEALTH GP TUTOR

Supervisors name: ___________________________ GP Practice:__________________________________




2) Confirmation of satisfactory completion of work-place based assessmentsMini CEX (1) [Y] [N] (2) [Y] [N]






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

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To be completed by student: Student Name: _____________________________________ DATES____________

Registration No_______________________________ Module: COMMUNITY & PUBLIC HEALTH SMALL GROUP

Supervisors name: ___________________________ GP Practice: (delete)__________________________________

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

separately.Cases discussed (List the cases keydiscussed during this attachment)

Feedback1) 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 assessmentsMini CEX (1) [Y] [N] (2) [Y] [N] N/A



5) Communication skillswith tutors and peers





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

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To be completed by student: Student Name: ____________________________________________________

Registration No_______________________________ Module: PSYCHIATRY DATES____________________

Supervisors name: ___________________________ Hospital:_________________________________________




2) Confirmation of satisfactory completion of work-place based assessmentsObserved Long Case [Y] [N]






Supervisors Address__________________________________ Date: _____________PLEASE RETURN THIS FORM TO

SARAH TURVEY ACADEMIC CLINICAL PSYCHIATRY, THE LONGLEY CENTRE, NORTHERN GENERAL HOSPITAL,HERRIES ROAD SHEFFIELD

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To be completed by student: Student Name: __________________________________________________

Registration No_______________________________ Module: NEUROLOGY DATES__________________

Supervisors name: ___________________________ GROUP :______________________________________


Cases Seen (Please tick or add thecases seen during this attachment)

Gait / coordination problems(14)

Problems with highercognitive function (15, 31, 33)

Coma / brain death (16)

Dizziness / vertigo (17)

Headaches (18, 20)

Blackouts / loss ofconsciousness (19, 23)

Movement disorder / tremor(21)

Altered sensation (22)

Visual field / cranial nerve

disorders (24)

Weakness (25)

Other (please add detailsbelow)

Feedback1) Presentation of patient on ward round (history taking, clinical examination,presentation and discussion of patients, including formative assessments)



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

5) Confirmation of satisfactory completion of work-place based assessmentsMini CEX (1) [Y] [N] (2) [Y] [N] Written Case History & examination ) [Y] [N]





JACQUIE HARRISON SCHOOL OF MEDICINE, MEDICAL SCHOOL, BEECH HILL ROAD SHEFFIELD

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To be completed by student: Student Name: ________________________________________ DATES ______________

Registration No_______________________________ Module: MEDICINE FOR OLDER PEOPLE

Supervisors name: ___________________________ Hospital/GROUP:_______________________________________________




2) Confirmation of satisfactory completion of work-place based assessmentsCase Study [Y] [N]


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

behaviours].







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6-week SSC ASSESSMENT PROFORMA: Phase 3a

To be compl eted by student: Student name_______________________________________________________________________________

Student Regist rat ion No________________________ Group _____________ Dates of SSC______________________________________

Supervisor/marker name________________________________________________________________________________________________

Supervisor/marker address_____________________________________________________________________________________________

Al l 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

Generic Graduate Skills

Excel len t Good Sat is factory Border line Unsat is factory

[Includes skills in writtencommunication, informationgathering, organisation and self-management].

Feedback for all grades please

(Continue overleaf)

SSC Specific Skills


These are defined by the studentand supervisor and shouldindicate clear aims, learninggoals and appropriateassessment

Feedback fo r all g rades please

(Continue overleaf)

IT Skills


i

[Word processed report, poster& abstract; presentation &abstract or other agreedassessment].


(Continue overleaf)

Overall Competence


Overall performance ongeneric and specific skills

for stage of training


(Continue overleaf)

Professional Behaviours


[Includes ensuring an ethicalapproach, avoiding plagiarism, &completion on time and asrequested].


(Continue overleaf))

Signature of Supervisor/marker____________________________________________________ Date___________________________________



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The Sheffield Core Curriculum Outcome Objectives for Undergraduate Medicine

Phase 3a 6-Week SSC


GS1 Adopts the principles of reflective practice and life-long learning

GS2 Knows the limits of professional competence

GS3 Presents info rmation 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 depthGS7 Can deal with uncertaintyGS8 Manages information retrieval, presentation and manipulation electronically

Interpersonal Skills IS1 Can establish, build and maintain proper partnerships with patients, their

family/friends/carers

IS2 Communicates effectively

IS3 Works effectively as a member of a multidisciplinary team

IS4 Deals sensitively with patients, their family/friends/carers

IS5 Identifies potential danger for self and others and takes appropriate action to limit impactClinical Skills CS1 Contributes to cure of illness, recovery from sickness and the easing of suffering anddiscomfort 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

CS4 Conducts complete mental state examination or selects appropriate componentsin a systematic and directed fashion

CS5 Conducts complete physical examination or selects appropriate components in asystematic and directed fashion

CS6 Makes accurate assessment of patient's problems & formulates differential diagnosisCS7 Selects & initiates appropriate investigations

CS8 Interprets and evaluates data from history, physical examination and other findings toformulate diagnosis

CS9 Formulates and implements management plan and monitors its effectiveness

Practical Skills PS1 Ensures optimum patient comfort and privacyPS2 Prepares patient for, explains & conducts technical and practical procedures

effectivelyPS3 Ensures patient consent is obtained in all aspects of investigation, treatment and

managementPS4 Can access relevant information and record information accuratelyPS5 Makes thorough and accurate observations, measurements and calculationsPS6 Recognises, identifies and can describe abnormalities and symptomsPS7 Demonstrates effective decision makingPS8 Manages life-threatening conditions

Professional Behaviours PB1 Adopts a questioning approach to own work and that of others

PB2 Works within limits of own knowledge and experiencePB3 Maintains patient confidentialityPB4 Is responsive to changes in health care, policy and current sciencePB5 Maintains an ethical approachPB6 Complies with legal responsibilities and requirements and guidelines of regulatory

bodies and the NHSPB7 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 teachPB10 Fulfils professional responsibilities in contexts inside & outside work

SSC Specific Outcomes

Able to identify own learning needs and negotiate those with supervisor

Fulfils learning needsFulfils agreed assessmentProduces a word-processed document which is formatted appropriately and uploaded to

the e-portfoli o

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1-week SSC ASSESSMENT PROFORMA: Psychiatry, Neurology, Medicine for Older People Phase 3a

To be completed by student:

Student Regist rat ion No________________________ Group _____________ Dates of SSC______________________________________

Supervisor/marker name________________________________________________________________________________________________

Supervisor/marker address_____________________________________________________________________________________________

Al l sect ions 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 outcomesagreed for this SSC. Professional Behaviours should be considered separately from the generic and specific skills assessments.

PLEASE CIRCLE THE APPROPRIATE JUDGEMENT



[Includes skills in writtencommunication, informationgathering, organisation and self-management].

Feedback for all grades please

(Continue overleaf)

SSC Specific Skills


[Understanding of the subject,able to write a structured essaywith reference to the literature.Critical analysis of the literature].


(Continue overleaf)

IT Skills


i

[Word processed report,formatted appropriately].


(Continue overleaf)

Overall Competence


Overall performance on

generic and specific skillsfor stage of training


(Continue overleaf)

Professional Behaviours

Sati sfac tor y B order li ne Uns ati sfac tor y

[Includes ensuring an ethicalapproach, avoiding plagiarism, &completion on time and asrequested].


(Continue overleaf))

Signature of Supervisor/marker____________________________________________________ Date___________________________________



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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


GS1 Adopts the principles of reflective practice and life-long learning

GS2 Knows the limits of professional competenceGS3 Presents information clearly in all formats

GS4 Is an effective teacher/mentorGS5 Capable of self-managementGS6 Appl ies research princ iples and audit and studies topics in depthGS7 Can deal with uncertaintyGS8 Manages information retrieval, presentation and manipulation electron ically

Interpersonal Skills IS1 Can establish, build and maintain proper partnerships with patients, theirfamily/friends/carers

IS2 Communicates effectively

IS3 Works effectively as a member of a multidisciplinary team

IS4 Deals sensitively with patients, their family/friends/carers

IS5 Identifies potential danger for self and others and takes appropriate action to limitimpact

Clinical Skills CS1 Contributes to cure of illness, recovery from sickness and the easing of sufferingand discomfort in encounters with patients

CS2 Participates in health promotion and in prevention of disease and disability inencounters with patients

CS3 Gathers relevant patient history information systematically either from patient orthird party

CS4 Conducts complete mental state examination or selects appropriate componentsin a systematic and directed fashion

CS5 Conducts complete physical examination or selects appropriate components in asystematic and directed fashion

CS6 Makes accurate assessment of patient's problems & formulates differentialdiagnosisCS7 Selects & initiates appropriate investigationsCS8 Interprets and evaluates data from history, physical examination and other findingsto formulate diagnosisCS9 Formulates and implements management plan and monitors its effectiveness

Practical Skills PS1 Ensures optimum patient comfort and privacyPS2 Prepares patient for, explains & conducts technical and practical procedureseffectivelyPS3 Ensures patient consent is obtained in all aspects of investigation, treatment andmanagementPS4 Can access relevant information and record information accuratelyPS5 Makes thorough and accurate observations, measurements and calculationsPS6 Recognises, identifies and can describe abnormalities and symptoms

PS7 Demonstrates effective decision makingPS8 Manages life-threatening conditions

Professional Behaviours PB1 Adopts a questioning approach to own work and that of othersPB2 Works within limits of own knowledge and experiencePB3 Maintains patient confidentialityPB4 Is responsive to changes in health care, pol icy and current sciencePB5 Maintains an ethical approachPB6 Complies with legal responsibilities and requirements and guidelines of regulatorybodies and the NHSPB7 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

SSC Specific Outcomes Understands the subjectAble to wri te in the sty le of a scient if ic paper

Can word-process a report which is formatted appropriately and uploaded to the e-portfolio

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