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Evaluating:  Resident, OR   Rotation:  OR   Month:  01/01/1980-01/31/1980
Patient Care Skills
Instructions:
Please score all subcategories as appropriate for the cases involved. You MUST give a score in categories A, E, and F. All others should be scored as appropriate. You MUST also assign an overall score which need not be an average of the subcategories but may reflect a weighting of individual areas based on the cases involved. Do NOT mark any area not applicable to the cases involved in this evaluation.
Overall---------->

Select ...At Expected Level

              Above Expected Level

              Below Expected Level

              Unacceptable

A.  Preoperative Evaluation and Anesthetic Planning Skills.

Select ..At Expected Level   

             Above Expected Level

             Below Expected Level

             Unacceptable

B.  Airway Management Skills.

Select .. At Expected Level

              Above Expected Level

              Below Expected Level

              Unacceptable

C.  Catheter Placement Skills.

Select .. At Expected Level

              Above Expected Level

              Below Expected Level

              Unacceptable

D.  Regional Anesthesia Skills.

Select .. At Expected Level

              Above Expected Level

              Below Expected Level

              Unacceptable

E.  Intraoperative Anesthetic Management.

Select ...At Expected Level

              Above Expected Level

              Below Expected Level

              Unacceptable

F.  Emergence Related Skills.

Select ...At Expected Level

              Above Expected Level

              Below Expected Level

              Unacceptable

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Evaluating:  Resident, OR   Rotation:  OR   Month:  01/01/1980-01/31/1980
Medical Knowledge
Instructions:
You MUST at least one category A-D. You MUST also assign an overall score which need not be an average of the subcategories but may reflect a weighting of individual areas based on the cases involved.
Overall---------->

Select .. At Expected Level

              Above Expected Level

              Below Expected Level

              Unacceptable

A.  Understands surgical procedures and anesthetic implications.

Select ...At Expected Level

             Above Expected Level

             Below Expected Level

             Unacceptable

B.  Understands pathophysiology of patients' surgical and medical illnesses, and anesthetic implications of these illnesses.

Select ...At Expected Level

             Above Expected Level

             Below Expected Level

             Unacceptable

C.  Shows basic science knowledge (physiology, pharmacology, anatomy) as related to patients.

Select ...At Expected Level

             Above Expected Level

             Below Expected Level

             Unacceptable

D.  Demonstrates specific knowledge of anesthetic techniques, drugs, and management options appropriate to the individual patient.

Select ...At Expected Level

             Above Expected Level

             Below Expected Level

             Unacceptable

E.  Understands pathophysiology of pain management syndromes and is able to discuss treatment options including pharmacotherapy, physical and occupational therapy, psychotherapy, and therapeutic procedures.

Select ...At Expected Level

             Above Expected Level

             Below Expected Level

             Unacceptable

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Evaluating:  Resident, OR   Rotation:  OR   Month:  01/01/1980-01/31/1980
Professionalism
Instructions:
Score Overall. Optionally Score A.-D. individually if there is a specific strength or problem.
Overall---------->

Select ...At Expected Level

              Above Expected Level

              Below Expected Level

              Unacceptable

A.  Motivation, Initiative, and Promptness

Select ...At Expected Level

              Above Expected Level

              Below Expected Level

              Unacceptable

B.  Reliability and Responsibility.

Select ...At Expected Level

              Above Expected Level

              Below Expected Level

              Unacceptable

C.  Integrity.

Select ...At Expected Level

              Above Expected Level

              Below Expected Level

              Unacceptable

D.  Attitude.

Select ...At Expected Level

              Above Expected Level

              Below Expected Level

Unacceptable

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Evaluating:  Resident, OR   Rotation:  OR   Month:  01/01/1980-01/31/1980
Interpersonal and Communication Skills
Instructions:
Score Overall. Optionally Score A.-D. individually if there is a specific strength or problem.
Overall---------->

Select ...At Expected Level

              Above Expected Level

              Below Expected Level

              Unacceptable

A.  Relationships and communication with surgical colleagues, medical and other consultants.

Select ...At Expected Level

              Above Expected Level

              Below Expected Level

              Unacceptable

B.  Relationships and communication with OR staff.

Select ...At Expected Level

              Above Expected Level

              Below Expected Level

              Unacceptable

C.  Relationships and communication with patients and their families.

Select ...At Expected Level

              Above Expected Level

              Below Expected Level

              Unacceptable

D.  Relationships and communication with anesthesiology faculty.

Select ...At Expected Level

              Above Expected Level

              Below Expected Level

              Unacceptable

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Evaluating:  Resident, OR   Rotation:  OR   Month:  01/01/1980-01/31/1980
Practice-based Learning
Instructions:
Do NOT score item C. Score Overall. Optionally Score A, B, D, or E individually if there is a specific strength or problem.
Overall---------->

Select ...At Expected Level

              Above Expected Level

              Below Expected Level

              Unacceptable

A.  Responds appropriately to faculty direction and criticism and demonstrates learning from faculty/resident interactions.

Select ...At Expected Level

              Above Expected Level

              Below Expected Level

              Unacceptable

B.  Appropriately utilizes general medical literature and anesthesiology literature to develop an anesthetic plan for their patients.

Select ...At Expected Level

              Above Expected Level

              Below Expected Level

              Unacceptable

C.  Is committed to self-education by attending Departmental educational activities including conferences, journal clubs and simulator sessions (this category will be filled out quarterly by the residency administration). This category will be filled in quarterly by office staff based on your attendance.
D.  Able to use information technology to manage information, access online medical information; and support their own education.

Select ...At Expected Level

              Above Expected Level

              Below Expected Level

              Unacceptable

E.  Facilitates the learning of students and other healthcare professionals.

Select ...At Expected Level

              Above Expected Level

              Below Expected Level

              Unacceptable

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Evaluating:  Resident, OR   Rotation:  OR   Month:  01/01/1980-01/31/1980
Systems-based Practice Skills
Instructions:
You MUST score Overall and subcategory D. Optionally score A, B, C and E individually if there is a specific strength or problem.
Overall---------->

Select ...At Expected Level

              Above Expected Level

              Below Expected Level

              Unacceptable

A.  Practices cost-effective healthcare that does not compromise patient care.

Select ...At Expected Level

              Above Expected Level

              Below Expected Level

              Unacceptable

B.  Appropriately utilizes consultants and diagnostic testing information to prepare the patient for surgery.

Select ...At Expected Level

              Above Expected Level

              Below Expected Level

              Unacceptable

C.  Recognizes and plans for appropriate postoperative followup care (including recognizing when a patient is an appropriate candidate for ambulatory surgery).

Select ...At Expected Level

              Above Expected Level

              Below Expected Level

              Unacceptable

D.  Recordkeeping skills - includes documentation of anesthetic as well as appropriate documentation of effort for reimbursement; demonstrates knowledge of and behavior consistent with strict medicare compliance.

Select ...At Expected Level

              Above Expected Level

              Below Expected Level

              Unacceptable

E.  Participates actively as an effective healthcare team member facilitating optimal and efficient patient care.

Select ...At Expected Level

              Above Expected Level

              Below Expected Level

              Unacceptable

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Evaluating:  Resident, OR   Rotation:  OR   Month:  01/01/1980-01/31/1980
Faculty Comments
Instructions:
Please add any comments you may have regarding this evaluation. If any questions have been scored "Below Expected Level" or "Unacceptable" you MUST include comments to continue.
Faculty comments are placed in this space.
Evaluating:  Resident, OR   Rotation:  OR   Month:  01/01/1980-01/31/1980
Resident Informed
Instructions:
Please say if you discussed this evaluation with the resident.
I did NOT discuss these evaluation results with the resident.
I have made the resident aware of my evaluation of their performance.
I am not sure if I discussed this evaluation with the resident.
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This final section will only appear for CA-3 level residents.

Evaluating:  Resident, OR   Rotation:  OR   Month:  01/01/1980-01/31/1980
Consultant Level
Instructions:
Please indicate if this resident is cabable of practicing independently.
Based on my interactions this week, this resident is capable of practicing independently as an anesthesiologist?
Yes No
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Revised 7/2004