Student Feedback Form Directly Observed Clinical Care Feedback Form Site Location:(Required)Choose your locationBatesvilleFort SmithJonesboroLittle RockNorth Little Rock – BaptistNWA-Springdale/FayettevillePine BluffTexarkanaStudent Name(Required) First Last Faculty or Resident Name(Required) First Last Please complete only the sections of this form that you directly observed. Leave any areas you did not observe blank.History TakingEffectiveness, pertinent details, organization and coherencePhysical exam skillsAbility to identify organ system exams relevant to chief concern / chronic disease – accuracy of exam technique, ability to identify abnormal findings without promptingDifferential Diagnosis / Assessment / Clinical Reasoning Skills Generates an appropriate and prioritized DD based on history, exam findings and pre-existing data – prior labs/imaging results Recognizes most likely diagnoses Includes relevant “do not miss” or serious life-threatening conditions and effectively excludes serious conditions through appropriate clinical reasoning/diagnostic work up/ treatment and follow up plan Diagnostic / Treatment PlanRecognizes first test and next best steps in diagnosing and managing a suspected clinical problem. Fund and Application of medical knowledgeAppropriate knowledge of relevant pathophysiology of disease process, drug classes, clinical indication and contraindications of commonly prescribed drugs Uses knowledge of clinical pathophysiology and pharmacology to suggest diagnostic / treatment plan Value added to clinical siteFunctions as a great team player, displays proactiveness and assists residents and primary care team members in providing patient education and communicates well with team members. Acknowledgement(Required)I have discussed the above feedback with the student and suggested a plan for further enhancement of knowledge and skills for practice of Family Medicine. AcknowledgementDate of Acknowledgement(Required) Month Day Year