APP_Initial FPPE_Caselogs Review Proctoring Form

___________________________________________________________________________________________

II .

Medical Knowledge : Adequate Knowledge demonstrated a . Demonstrates good investigative and analytical thinking . b . Demonstrates knowledge and application of basic sciences .

� No Concerns

� Concerns / explanation : ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________

III .

Practice-Based Learning : Evidence of use of resources and guidelines a . Analyzes own practice for needed improvements . b . Uses information communication and technology .

� No Concerns

Name of Medical Staff Practitioner : _____________________________________________________ Name of Proctor / Mentor : ____________________________________________________________

IV . Communication & Interpersonal Skills : Good rapport ( peers , residents , patients , staff ) a . Accurately conveys relevant information to patients , families , and colleagues . b . Respects patient confidentiality , privacy and autonomy . c . Listen effectively .

� No Concerns

V . Professionalism : a . Courteous , appropriate , pleasant demeanor b . Is respectful of all members of the healthcare team . c . Is respected by patients and staff d . Is sensitive to cultural , age , gender , and disability issues .

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APP_Initial FPPE_Caselogs Review Proctoring Form | Page 3