Medical Student Clinical Assessment Form

Please submit this signed form via email to AUC’s Office of the Registrar:
aucregistrar@aucmed.edu
880 SW 145th Ave., Suite 202, Pembroke Pines, FL 33027 • Tel: 305.446.0600
Student Name: ______________________________________ Clinical Site: ____________________________________
Student Number: ___________________________________ City & Country: ________________________________
Core Clerkship/Elective: ___________________________ Date Started (mm/dd/yy): _______________________
Specialty: ____________________________________________ Date Ended (mm/dd/yy): ________________________

Observation Setting: Inpatient Outpatient Both

Instructions for using this form:

An individualized mid-clerkship review at the midpoint of every core clerkship or elective is
required for all students; a formal mid-clerkship review and a written remediation plan is mandatory
for any student whose performance is deficient (defined as either below expectations or failing in one
or more categories – see below).

Summative assessments are used at the end of core clerkships and electives to determine whether
students have mastered the Association of American Medical Colleges’ entrustable professional
activities (EPAs)1 and specific Accreditation Council for Graduate Medical Education (ACGME)
competencies.2 This assessment form is to be completed at the end of each clinical rotation (twelve-
week core clerkship, six-week core clerkship, or an elective). If there are multiple sources of
information on a student’s performance, then the Clerkship or Elective Director is expected to
incorporate that information into one assessment form for the rotation. Only one Medical Student
Clinical Assessment Form should be submitted for each student within 30 days of the end of
each clerkship or elective.

Medical educators who are completing Medical Student Clinical Assessment Forms should be aware of
the stage at which the student is in their course of learning. For example, if this is a student’s final
clinical rotation or placement, expectations are naturally higher than if the student has not previously
undertaken any clinical rotations or placements.

Rating scale:
Exceeds expectations: Is an advanced student who functions consistently at a level higher than is
usual for this stage of training.
Meets expectations: Is a capable student who performs consistently at a level appropriate for this
stage of training with no serious weaknesses with respect to that specific clinical skill or category.
Below expectations: Falls short of an adequate performance in a specific clinical skill or category.
Has weaknesses that need addressing. May have received mid-clerkship feedback identifying the
relevant issues and has made a partial remedial response. For any student who receives this
rating in one or more areas, this assessment form must include a specific description of feedback
given to student, level of response, and areas in need of further remediation in the Comments
section.
Fail: Has serious weaknesses. Falls substantially short of an adequate performance in this category.
May have received mid-clerkship feedback identifying the issues, but has not subsequently acted
on it or improved. For any student who receives this rating in one or more areas, this assessment
form must include detailed comments to identify and describe the issues, feedback provided, and
persistent problems in the Comments section.

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1. MEDICAL INTERVIEWING SKILLS: The ability to take an effective history from a patient and/or patient representative
[EPA 11; ACGME competency: patient care2].
Exceeds expectations Meets expectations Below expectations Fail

2. PHYSICAL EXAMINATION SKILLS: The ability to perform an appropriate and accurate physical examination [EPA 1;
ACGME: patient care].
Exceeds expectations Meets expectations Below expectations Fail

3. COMMUNICATION WITH PATIENTS AND FAMILIES: The ability to communicate effectively with patients and their
family members or designated health advocates [EPA 3,4,11; ACGME: interpersonal and communication skills].
Exceeds expectations Meets expectations Below expectations Fail

4. COMMUNICATION WITH OTHER HEALTH CARE PROVIDERS: The ability to communicate effectively with other
health professionals in a variety of ways: 1) verbally - both in person and remotely - with concise, well organized oral
presentations and 2) in writing using accurate and timely written documentation [EPAs 4,5,6,8,9; ACGME: interpersonal
and communication skills].
Exceeds expectations Meets expectations Below expectations Fail

5. MEDICAL KNOWLEDGE: The foundational knowledge of established clinical care, use of evidence-based medicine, and
utilization of health care resources [EPAs 2,3,7; ACGME: medical knowledge].
Exceeds expectations Meets expectations Below expectations Fail

6. CLINICAL REASONING SKILLS: The ability to make a differential diagnosis, request appropriate diagnostic tests, and
make an evidenced-based management plan; problem-solving capacity [EPAs 2,3,10; ACGME: patient care].
Exceeds expectations Meets expectations Below expectations Fail

7. PROCEDURAL SKILLS: The ability to perform procedures in a capacity appropriate to stage of training [EPA 12;
ACGME: patient care].
Exceeds expectations Meets expectations Below expectations Fail N/A

8. SYSTEMS-BASED PRACTICE: Displays a safe attitude to patient care, can recognise a critically ill patient, safeguards
patient safety, knows when to seek help, has situational judgement, and is familiar with systems-based practice [EPA
10,13; ACGME: system-based practice].
Exceeds expectations Meets expectations Below expectations Fail

9. SELF-DIRECTED LEARNING SKILLS: Has insight into own strengths and weaknesses and can articulate a self-directed
plan for improvement, both verbally and in writing, demonstrates initiative [EPAs 1-13; ACGME: practice-based learning
and improvement].
Exceeds expectations Meets expectations Below expectations Fail

10. PROFESSIONALISM: Punctuality, attendance, appearance, behavior, teamwork, probity, honesty, and integrity [EPAs 1-
13; ACGME: professionalism]
Exceeds expectations Meets expectations Below expectations Fail

11. OVERALL: Rate this student’s overall performance in a clinical setting during this core clerkship or elective
[EPAs 1-13; ACGME: all 6 competencies]

Exceeds expectations Meets expectations Fail

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Summative comments which will be AUTOMATICALLY INCLUDED in the student’s
Medical Student Performance Evaluation (MSPE), a key component of the residency
application process:

[Summative comments are required]

Formative comments / additional suggestions which will NOT be included in the

student’s MSPE / residency application but will be used for self-improvement:

[Formative comments / additional suggestions are optional]

____________________________________________________________________ ____________________________________________________________________
Signature of Core Clerkship / Elective Director Signature of Site Director

____________________________________________________________________ ____________________________________________________________________
Name of Core Clerkship / Elective Director (please print) Name of Site Director / Hospital (please print)

_____________________________ ____________________________
Date Signed (mm/dd/yy) Date Signed (mm/dd/yy)

ACKNOWLEDGEMENT BY THE STUDENT

I have read this assessment and discussed it with a faculty member.

Student’s Signature: ________________________________________________ Date Signed (mm/dd/yy): __________________________

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Medical Education Resources at American University of the Caribbean School of Medicine:
If you have any concerns about a student’s performance or professionalism during a clinical clerkship
or elective, please do not hesitate to contact AUC’s Associate Clinical Dean, Student Affairs, Dr.
Kimberly Kirkland at kkirkland@aucmed.edu.

If you have any concerns about a student’s performance at the end of a clerkship or what information
to include in the summary assessment form:
For students at US sites, please do not hesitate to contact AUC’s Associate Clinical Dean – US, Dr.
Robert Hecht at rhecht@aucmed.edu.
For students at UK sites, please do not hesitate to contact AUC’s Clinical Dean – UK, Dr. Stephen Ash at
sash@aucmed.edu.

American University of the Caribbean School of Medicine (AUC) Program Objectives (revised in 2016):
http://aucmed.edu/academics.aspx

Medical Education Resources:

1Thirteen entrustable professional activities (EPAs) launched by the Association of American Medical

Colleges (AAMC) in 2014:

http://members.aamc.org/eweb/upload/Core%20EPA%20Curriculum%20Dev%20Guide.pdf
1: Gather a history and perform a physical examination
2: Develop a prioritized differential diagnosis and select a working diagnosis following a patient
encounter
3: Recommend and interpret common diagnostic and screening tests
4: Enter and discuss patient orders/prescriptions
5: Provide documentation of a clinical encounter in written or electronic format
6: Provide an oral presentation/summary of a patient encounter
7: Form clinical questions and retrieve evidence to advance patient care
8: Give/receive a patient handover to transition care responsibility to another health care
provider or team
9: Participate as a contributing and integrated member of an interprofessional team
10: Recognize a patient requiring urgent or emergent care, initiate evaluation and treatment, and
seek help
11: Obtain informed consent for tests and/or procedures that the day 1 intern is expected to
perform or order without supervision
12: Perform general procedures of a physician
13: Identify system failures and contribute to a culture of safety and improvement

2Six
competencies launched by the Accreditation Council for Graduate Medical Education (ACGME) in
1999 and updated in 2013: http://www.acgme.org/
Patient care (Questions 1, 2, 6, and 7)
Medical knowledge (Question 5)
Practice-based learning and improvement (Question 9)
Interpersonal and communication skills (Questions 3 and 4)
Professionalism (Question 10)
System-based practice (Question 8)

Please submit this signed form via email to AUC/Office of the Registrar:
aucregistrar@aucmed.edu

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