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Campbell University School of Pharmacy

STUDENT CLERKSHIP EVALUATION FORM

Name:

Preceptor/Rotation Site:

Date:

The student's performance is based upon the following rating scale: (Please use only the numbers listed below, unless no credit (0) is given)

3 deficits exist	3.5 Marginal	3.75 FAIR	4.25 good	4.5 Very good	5+ exceptional
Needs extensive interventions; Sometimes the preceptor must complete the task	Needs consistent intervention; Preceptor must provide directed questioning in a problem-solving manner	Needs frequent intervention; preceptor provides occasional prompts	Requires occasional interventions consisting of single limited prompt. Performs within expectations	Requires infrequent or rare interventions; Performs above expectations most of the time	Requires no interventions; Consistently performs above expectations; The student teaches the faculty something new

This evaluation form will be used to derive 70% of the student grade for required rotations in Drug Information. Supplemental criteria (standardized by area of practice) will be used to determine the remaining 30% of the grade.

I. BASIC INFORMATION

A. Knowledge of Problems/Disease States

The student can describe the pathophysiology, prognosis, clinical presentation, and list appropriate therapies for each patient problem.

3

3.5

3.75

4.25

4.5

5

Comments:

B. Drug Knowledge:

Level of understanding regarding the drug class, mechanisms of action, dosing, common adverse reactions, drug interactions, and monitoring parameters.

3

3.5

3.75

4.25

4.5

5

Comments:

Subtotal = ____ x 2 = _____ points

II. DRUG INFORMATION SKILLS

A. Appropriate Use of Resources

Effectively utilize the primary, secondary, and tertiary literature, and available computer equipment.

3

3.5

3.75

4.25

4.5

5

Comments:

B. Literature Evaluation

Demonstrate the ability to evaluate the pharmacy and medical literature.

3

3.5

3.75

4.25

4.5

5

Comments:

C. Data Collection:

1. Obtain appropriate patient, drug, and disease information from an inquirer.

3

3.5

3.75

4.25

4.5

5

Comments:

2. Effectively communicate with inquirers utilizing the drug information center and those with which the center has consulted.

3

3.5

3.75

4.25

4.5

5

Comments:

D. Application of Information

1. Ability to organize information and establish priorities when responding to inquiries.

3

3.5

3.75

4.25

4.5

5

Comments:

2. Apply the obtained information from appropriate sources to the specific drug information question.

3

3.5

3.75

4.25

4.5

5

Comments:

3. Write concise, grammatically correct, and clinically applicable consultations, drug monographs

and other drug-related manuscripts.

3

3.5

3.75

4.25

4.5

5

Comments:

4. Ability to appropriately document drug information responses and the search strategies utilized.

Ability to use quality assurance techniques in evaluating those drug information responses.

3

3.5

3.75

4.25

4.5

5

Comments:

Subtotal = _________ x .875 = __________points

III. INTERPERSONAL SKILLS

3 deficits exist	3.5 Marginal	3.75 FAIR	4.25 good	4.5 Very good	5 exceptional
demonstrates inability to perform or lack of understanding in this	requires significant interventions	Requires occasional intervention	Performs within expectations	Performs above expectations most of the time	consistently Performs above expectations

A. Professionalism and Maturity

Demonstrates judgement, initiative, responsibility, and maturity. The student displays a cooperative attitude and is receptive to feedback.

3

3.5

3.75

4.25

4.5

5

Comments:

B. Communication Skills

Displays an appropriate level of communication skills (verbal and written) during case presentations, projects, and during interactions with patients, physicians, and other health care professionals.

3

3.5

3.75

4.25

4.5

5

Comments:

3 deficits exist	3.5 Marginal	3.75 Fair	4.25 good	4.5 Very good	5 exceptional
Failed to meet many deadlines or; one unexcused absence or; consistently tardy to patient care activities	Missed a deadline for a major requirement or several activities not completed in a timely manner or; occasionally tardy to patient care activities	Achieves this standard with occasional exceptions	Always achieves this standard	Achieves this standard , plus shows significant advance planning and completes some projects ahead of time	consistently plans ahead, completing all projects in advance of requirements; motivates other students to work ahead

C. Timeliness and Dependability

Responds to assignments and responsibilities in a timely manner. Is consistently on time for patient care activities, group discussions and meetings. The student has no unexcused absences.

3

3.5

3.75

4.25

4.5

5

Comments:

Subtotal = ______ /15 points

FINAL GRADE

Part 1. Essential Performance Objectives (70%)

I. Basic Information: _____ / 20 points

II. Drug Information Skills: _____ / 35 points

III. Interpersonal Skills: _____ / 15 points

TOTAL: _____ / 70 points

Part 2. Variable Performance Objectives (30%)

Weekly case presentations:

Drug monograph:

Drug information question:

Journal club:

Inservice education:

FARM or SOAP note(s):

Projects:

Other:

Total: ______/30 points

Instructor(s) Comments:

FINAL GRADE = Part 1 + Part 2 = ______________

The point value will be converted to a letter grade based upon the following scale:

90 – 100 = A

80 - 89 = B

70 - 79 = C

< 70 = Failing

Total hours spent in clerkship: > 160

Preceptors Signature _______________________________________________Date: _______________

Students Signature* ________________________________________________Date: _______________

* Denotes only that the student has been shown how the grade (evaluation) was determined by preceptor.