This Logbook Belongs to ASMPH Clinical Clerk: ______________________, ID # ____________

YL8 RATING SCALE FOR PERFORMAN CE

Year Level 8 (Clerk)

Case Discussion Evaluation Form
Name of Clerk:
Evaluator:
Topic/Case:

LEC No.

Date:
Hospital/Institution:
Rotation/Department:

Instructions: Kindly encircle the score and indicate the total score.
0 = Not obtained
2 = Very Poor
4 = Poor
6 = Good
8 = Very Good
10 = Excellent
How did the clerk present/discuss the following parameters in the case presented?
Patient Information, Chief Complaint, History of Present Illness, Temporal Profile
Complete, accurate & pertinent patient information
Pertinent & appropriate clinical manifestation/complaint
Complete, accurate, pertinent & logical sequence of HPI/Temporal profile
Subjective
Pertinent Medical History
PMH, Medication history, Food/drug allergy, Surgical history
Family history, Genogram
Sexual history/Personal/Social/Environmental history
If Pediatric: Birth history, nutrition, immunization, developmental (Milestones, HEADSSS)
Physical examination findings
Pertinent to the case
Objective
Performed & presented in proper sequence
Correct description of findings
Main Diagnosis/Initial Impression
Appropriate problem list
Supported by pertinent salient features
Assessment Provided adequate correlation.
Differential Diagnosis
Supported by pertinent exclusion criteria
Provided adequate correlation.
Diagnostic
Recommended/Requested appropriate tests/procedures
Discussed the rationale of each test/procedure
Therapeutic
Recommended/Requested appropriate medical treatment or surgical
Plan
intervention/procedure
Discussed the rationale of the medical treatment or surgical intervention/procedure
Discussed the adverse outcomes or complications of medical treatment or surgical
intervention/procedure
Preventive
Explained appropriate preventive health care measures for the patient and family.
Clinical course
Explained the underlying pathophysiology of the clinical condition
Explained the patients response/clinical course to treatment/intervention.
Discussion
Contextual analysis
Made a concise, fairly complete & pertinent contextual analysis of the patients over-all
biologic, psychological, socio-economic, and spiritual status.
Stakeholder analysis
Comments:

ASMPH Clinical Clerks Logbook SY 2016-2017

Score
0

2 4 6 8 10

2 4 6 8 10

2 4 6 8 10

2 4 6 8 10

2 4 6 8 10

2 4 6 8 10

2 4 6 8 10

2 4 6 8 10

2 4 6 8 10

2 4 6 8 10

Total
/100

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This Logbook Belongs to ASMPH Clinical Clerk: ______________________, ID # ____________

YL8 RATING SCALE FOR PERFORMANCE
(SKILLS)
Name of Clerk: ________________________ LEC No. ______
Rotation: ____________________

Date: _______________

Hospital: _______________________________

Procedure: ____________________________________________________________________
Lowest

Highest

Made sure that the correct procedure was being done

to the correct patient at the correct site

0.25

0.5

0.75 1 1.25 1.5 1.75

Maintained good rapport with the patient, including

making an effort to put the patient at ease and to
minimize discomfort and pain

0.25

0.5

0.75 1 1.25 1.5 1.75

Paid meticulous attention to basic asepsis and

antisepsis techniques

0.25

0.5

0.75 1 1.25 1.5 1.75

Paid strict and meticulous attention to basic surgical

/ procedural techniques throughout the procedure

0.25

0.5

0.75 1 1.25 1.5 1.75

Correctly used the proper instruments during the

entire procedure

0.25

0.5

0.75 1 1.25 1.5 1.75

FINAL SCORE

Consultants Signature

________________________________

Consultants Name

________________________________

ASMPH Clinical Clerks Logbook SY 2016-2017

Page 110 of 116

This Logbook Belongs to ASMPH Clinical Clerk: ______________________, ID # ____________

YL8 RATING SCALE FOR PROFESSIONALISM
Name of Clerk: _____________________

LEC No. ______

Date: ______________

Rotation: ____________________

Hospital: _____________________________________
Lowest

Has good working relationship with other team

members, enhances the value of the team

0.1

Highest
0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1.0

Shows proper respect for patients, peers, faculty, and

allied health personnel

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1.0

Shows sensitivity and compassion to patients

culture, age, gender, and disabilities

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1.0

Maintains honesty and integrity at all times

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1.0

Demonstrates a commitment to ethical principles

(confidentiality of patient information, informed
consent, provision or withholding of clinical care,
and business practices)

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1.0

Demonstrates initiative and a desire for excellence

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1.0

Accepts limitations and failings, open to feedback

and criticism, shows desire for self-improvement

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1.0

Maintains a professional demeanor in manner, dress

and action, and excludes self-confidence

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1.0

Demonstrates organizational ability, responsibility,

dependability

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1.0

Punctual and complete attendance

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1.0

FINAL SCORE

Evaluators Signature

________________________________

Evaluators Name

________________________________

Evaluators Position

Consultant
Resident
Intern

ASMPH Clinical Clerks Logbook SY 2016-2017

Page 111 of 116

This Logbook Belongs to ASMPH Clinical Clerk: ______________________, ID # ____________

YL8 RATING SCALE FOR PROGRESS NOTES

Name of Clerk: __________________ LEC No. ______

Date: _____________

Rotation: ______________________________

Hospital: _________

Case/Topic: __________________________________________________________
Lowest

Highest

S (Subjective)
Did the clerk .
record pertinent patient symptoms and give an appropriate
description of the symptoms?
note presence/absence of progress or relief from symptoms?
correctly quantify and/or qualify the symptoms of the patient?
O (Objective)
Did the clerk .
write/draw a focused physical examination of the patient?
(Vital signs, general appearance, mental status exam, HEENT
drawing if applicable, pertinent negatives, etc)
record findings of special tests/maneuvers, pertinent
laboratory findings/results? (CBC, Chest x-ray, CT scan,
histopathology report, etc)
A (Assessment)
Did the clerk .
state the complete working diagnosis/diagnoses?
note whether condition is improving, resolving, worsenining
or the same
list any differential diagnosis if working diagnosis is uncertain?
P (Plan)
Did the clerk .
list the plan, test/s, work up for each problem?
specify medications? (dosage, route and frequency)

1.5

2.5

1.5

2.5

1.5

2.5

1.5

2.5

FINAL SCORE (10/10)

Comments:

Evaluators signature ______________________________

Evaluators name
______________________________
ASMPH Clinical Clerks Logbook SY 2016-2017

Page 112 of 116

This Logbook Belongs to ASMPH Clinical Clerk: ______________________, ID # ____________

CLERKS EVALUATION O F THE TRAINING INSTI TUTION

ASMPH Clinical Clerks Logbook SY 2016-2017

Page 113 of 116

This Logbook Belongs to ASMPH Clinical Clerk: ______________________, ID # ____________

YL8 RATING SCALE FOR PROFESSIONALISM

PEER EVALUATION
Name of Clerk:__________________________

LEC No._____

Date: ____________

Directions:
1.
2.
3.

You must FORCE RANK your LEC group mates, giving 1.0 to the highest ranking groupmate, then 0.9 to the
next highest, then 0.8 to the next, and so forth until 0.4 for the lowest, for each of the four parameters.
No two clerks should have exactly the same grade within each of the four parameters.
Include YOURSELF in your ranking.
NAME

Interpersonal Relationships
Has good working relationship
with other team members,
enhances the value of the team
Shows proper respect for
patients, peers, faculty, and allied
health personnel
Shows sensitivity and compassion
to patients culture, age, gender,
and disabilities

Interpersonal
Relationships

Professional Integrity

Professional Integrity

Work

Professional Demeanor

Ethic

Work Ethic

Maintains honesty and integrity at

all times

Demonstrates initiative and a

desire for excellence

Demonstrates a commitment to
ethical principles (confidentiality of
patient information, informed consent,
provision or withholding of clinical care,
and business practices)

Accepts limitations and failings,

open to feedback and criticism,
shows desire for selfimprovement

Professional Demeanor
Maintains a professional demeanor
in manner, dress and action, and
excludes self-confidence
Demonstrates organizational
ability, responsibility, dependability
Punctual and complete attendance

You may also write any particular comments you may have, whether critical or commendatory, regarding
particular groupmates in the space below:

Evaluators Signature
Evaluators Name

________________________________
________________________________

ASMPH Clinical Clerks Logbook SY 2016-2017

Page 114 of 116

This Logbook Belongs to ASMPH Clinical Clerk: ______________________, ID # ____________

ATENEO SCHOOL OF MEDICINE AND PUBLIC HEALTH

YEAR LEVEL 8
SY 2015-2016
C L E A R A N C E
Students Name: ______________________________ ID Number: ___________
Rotations

Rotation Coordinator/
MBA Coordinators
Signature

Remarks

Medicine
Pediatrics
Surgery
Obstetrics and Gynecology
Orthopedics
Ophthalmology
ENT
Psychiatry
Radiology
Rehabilitation Medicine
Family Medicine
Ethics
Marketing Management
Financial Management
Operations Management
Strategic Management
Leadership
LEC

** All deficiencies must be completed on or before June 2017

Students Signature: ____________________________

Date: _____________________

Approved By:
Dr. Princess Carlos-Dollaga
YL8 Assistant Coordinator
Date: _____________________

ASMPH Clinical Clerks Logbook SY 2016-2017

Dr. Roberto C. Tanchanco

YL8 Coordinator
Date: _____________________

Page 115 of 116