year 5 caf 2015 16 jb

COLLECTED ASSESSMENT FORMS

YEAR 5: 2015/2016

NAME

E-MAIL

The material collected in this document should be used together with the QMUL Academic Regulations and the Student Guide. These are available at www.arcs.qmul.ac.uk. This document provides information specific to Barts and The London School of Medicine and Dentistry (SMD), while the Student Guide gives information common to all students of the College. The Academic Regulations provide detailed information on all aspects of award requirements and governance.

NOTHING PRINTED IN THIS DOCUMENT OVERRIDES THE ACADEMIC REGULATIONS WHICH ALWAYS TAKE PRECEDENCE.

Handbooks for each module of year 5, the scheme for assessment and all SMD policies and regulations are available electronically on QM+

The information in this document was correct at the time of printing. In the event of any substantial amendments to the information herein, the SMD will attempt to inform students of the changes. SMD cannot accept responsibility for the accuracy or reliability of information given in third party publications or websites referred to in this handbook.

CONTENTS

Introduction …………………………………….3

CAF submission checklist …………………………………….3

Surgery & anaesthesia and critical care …………………………………….4MSF forms 5ACC module activity form 11Year 5 core element grading criteria 12Surgery end of placement forms 13ACC end of placement forms 16

General internal medicine & emergency medicine …………………………………….19CBD form 20MSF forms 21GIM end of placement forms 26EM end of placement forms 29

Other assessments in year 5 …………………………………….32

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YEAR 5 Collected Assessment Forms 2015/16 © School of Medicine and Dentistry, QMUL

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INTRODUCTIONThis document is designed to provide in one place most of the assessment forms you will need to have completed by supervising practitioners during the first half of year 5. Guidance on what is expected of you is available in each module’s handbook and in the scheme for assessment for MBBS Part 5, both of which are available on QM+. The Year 5 Student Logbook should be used day to day on clinical placements to collect evidence of your progress towards foundation level competence in the various clinical skills listed in Tomorrow’s Doctors (GMC 2009).

The completed forms included here, as well as your logbook need to be submitted to the Phase 3 team in the Student Office in the Garrod Building by 4pm on March 4th 2016. Please take and retain a copy of every submitted element. Use the checklist below to help you remember everything. It will be signed and returned to you as a receipt.

CAF SUBMISSION CHECKLIST

SURGERY & ANAESTHESIA AND CRITICAL CARE

1. ONE case summary + reflection 2. ONE ACC module activity form3. FIVE multi-source feedback forms4. TWO completed end of firm assessment sheets 5. TWO completed professionalism assessmentsGENERAL INTERNAL MEDICINE & EMERGENCY MEDICINE

1. ONE case based discussion (CBD)2. FIVE multi-source feedback forms3. TWO completed end of firm assessment sheets 4. TWO completed professionalism assessmentsOTHER DOCUMENTS

Year 5 logbook (you will continue to collect evidence of your progress within this until the end of June 2016, but please submit it at this time. p13/14 will be removed and the book returned to you)

FIRST NAME

LAST NAME

EMAIL @qmul.ac.uk

Student Office Use Only

PRINT NAME (Staff)

SIGNATURE

DATE

SURGERY & ANAESTHETIA AND CRITICAL CARE ___________________________________________________________________________________________________________________


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Multi-source feedback (MSF)Students are required to submit 5 (MSF) forms collected during the six weeks spent on placement in Surgery & Anaesthetics and ITU. MSF is an assessment tool which allows you to collect opinions from people around you about your behaviour in the workplace. It is a good way of identifying areas for professional development.

Your assessors should include a range of people from your placement including consultants, GPs, other career grade doctors, doctors in training, nurses, therapists, pharmacists, ward clerks, administrators, secretaries & auxiliary staff.

You will be assessed on:1. Good clinical care2. Maintaining good medical practice3. Relationships with patients4. Working with colleagues

There is space on the form for you to write an action plan in response to each assessor’s comments.

Case summary & reflection Please present your writing to your supervising consultant in either surgery or ACC. It should not be longer than 2-sides of A4 and will be in two sections.

1. A summary of the patient in the form that would be used for handover to a colleague. You should keep this to one paragraph

2. A reflective discussion section addressing principles of Good Medical Practice (GMC 2013). You may wish to structure this second part as follows: A short description - what happened; what am I looking at? Interpretation – what are the important or salient features? Outcomes – what have I learnt from this; how will this impact me in the

future?

Reflect on your own experiences as much as possible rather than observing others, as this will improve your own self-awareness. The example you take should be an interesting, difficult or uncomfortable experience. Try to record both positive and negative elements. The important thing is that you demonstrate ability to reflect and show what you have learnt from these experiences and can identify further learning needs.

Please use the Helvetica or Verdana font, 11 point, single spacing

Module activity form – Anaesthesia & Critical CarePlease record the clinical programme you follow over the three weeks together with evidence of taking part in:

an on call period a pre-assessment clinic a pain ward round an ICU case presentation

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YEAR 5 SURGERY & ANAESTHESIA & CRITICAL CARE: MULTI-SOURCE FEEDBACK FORM 1

STUDENT NAME

TEACHING HOSPITAL DATES

GRADING SCALE AND FEEDBACK1 Below expectations for a final year student2 Borderline for a final year student3 Meets the expectation for a final year student4 Above the expectation for a final year studentUC Please mark this if you have not observed the behaviour and therefore feel unable to commentPlease grade the following areas (please circle) using the above scale on the basis of your expectation of a final year student ready to commence duties as a foundation year 1 trainee

GOOD CLINICAL CAREAbility to diagnose patient problems 1 2 3 4 UCAbility to formulate appropriate management plans 1 2 3 4 UCAwareness of their own limitations 1 2 3 4 UCAbility to respond to psychosocial aspects of illness 1 2 3 4 UCAppropriate utilisation of resources e.g. shadow ordering of investigations 1 2 3 4 UCMAINTAINING GOOD MEDICAL PRACTICEAbility to manage time effectively and prioritise 1 2 3 4 UCTechnical skills (appropriate to current level) 1 2 3 4 UCRELATIONSHIPS WITH PATIENTSRelationships with patients 1 2 3 4 UCCommunication with patients 1 2 3 4 UCRespect for patients and their right to confidentiality 1 2 3 4 UCWORKING WITH COLLEAGUESVerbal communication skills 1 2 3 4 UCWritten communication skills 1 2 3 4 UCAbility to recognise and value the contribution of others 1 2 3 4 UCAccessibility and reliability 1 2 3 4 UCOVERALL 1 2 3 4 UCPlease use this box to comment on areas of excellence (please continue on reverse if necessary)

Please use this box to make suggestions for development (please continue on reverse if necessary)

Action plan (student to complete, please continue on reverse if necessary)

Please return this form to the student, who should file it in their portfolio, and retain a copy if you wish.

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STUDENT NAME







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6


STUDENT NAME







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STUDENT NAME







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STUDENT NAME







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YEAR 5 ANAESTHESIA & CRITICAL CARE; Module Activity Summary

At the end of each day, please record your activity

Week 1 AM PM One thing I have learned today…

Monday

Tuesday

Wednesday SPORT

Thursday

Friday

Week 2 AM PM

Monday

Tuesday

Wednesday SPORT

Thursday

Friday

Week 3 AM PM

Monday

Tuesday

Wednesday SPORT

Thursday

Friday

On Call _____________________________________________________________________________Signature and Date

Pain Ward Round ____________________________________________________________________Signature and Date

ICU case Presentation ________________________________________________________________Signature and Date

Nurse shadowing HDU/ICU ____________________________________________________________Signature and Date

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Module Sign Off:

Name and Signature

WORKSHEET (OPTIONAL)Patient details:Age, Gender, Ethnicity

ASA status

Presenting Problem

Anaesthetic challenge

Solutions?

ASA 1 A normal healthy patient ASA 2 A patient with mild systemic disease ASA3 A patient with severe systemic disease, that limits function, but is not incapacitating. ASA 4 A patient with severe systemic disease that is a constant threat to lifeASA 5 A moribund patient who is not expected to survive without the operation. ASA 6 A declared brain-dead patient whose organs are being removed for donor purposes. Suffix E emergency procedure

3 things I have learned today…1

2

3

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Date__________________________________

Student_______________________________

Tutor_________________________________

YEAR 5 CORE ELEMENT GRADING CRITERIAThe Assessor should award each student an overall assessment after consultation with the appropriate tutors – including junior members of staff – who have been in close contact with the student. Students should be assessed as individuals and all students on a placement should only exceptionally receive the same assessment.

ATTRIBUTE PASS [P] FAIL [F]Attendance Good or acceptable record Poor record

Unexplained absencesKnowledge Good or adequate knowledge

and satisfactorily able to relate this to patient care.Learns from experience.

Uninterested - does not read relevant literature.Fails to apply basic science to clinical problems.Unable to construct a differential diagnosis with judgement.

Communication Skills

Sound, caring attitude.Takes time, listens and explains well.Competent and logical.

Poor listener and communicator.Explanations lack precision and clarity.

Practical Skills Usually complete, orderly and systematic history and examination.Can elicit correct signs and recognise most significant findings.Orderly and logical approach.

Incomplete, inaccurate and poorly recorded history and examination.Lacks basic skills.

Case summary and reflection

Clear and comprehensive summary of patient case.Clear and considered reflection.Able to identify own learning and further learning needs.Able to discuss selected themes with clinician in a thoughtful manner.

Poorly constructed summary.Focuses only on biomedical aspects.Does not cover professional practice issues or has a superficial manner.Unable to identify own learning and further needs.Unable to discuss selected themes with a clinician in a thoughtful manner.

Clinical reasoning

Able to use the information obtained from history and examination to construct a differential diagnosis and interrogate this by ordering reasonable investigations.Able to interpret investigations to build towards a definitive diagnosis.Accepts uncertainty

Unable to analyse clinical information.Jumps to premature and inappropriate conclusions.

MSF Please discuss the students MSF forms with the student and make a summary statement

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YEAR 5 SURGERY END OF PLACEMENT ASSESSMENT FORM

STUDENT NAME


Please refer to the year 5 core element grading criteria on page 12 for grading and feedback instructions and tick the appropriate box below

PASS FAIL PASS FAILAttendance Knowledge

Communication skills Practical skills

Case summary and reflection (Surgery or ACC)

Clinical reasoning

Multi-source feedback (MSF) synthesis

PROFESSIONALISMPlease complete the professionalism assessment form

OVERALL GRADE AWARDED – PLEASE CIRCLE ONE OPTION ONLY

PASS FAIL

Assessor’s general comments: Please comment on any favourable areas or any areas to which the student should be asked to pay special attention and on any factors, which may have interfered with the learning of the student. A COMMENT MUST BE ENTERED FOR ALL FAILED STUDENTS

NAME OF ASSESSOR

SIGNATURE OF ASSESSOR DATE Student DeclarationI have been absent from the attachment for the following number of days (including half days). If you have NOT been absent please write 0No. Days Absent STUDENT SIGNATURE DATE

The student’s performance should be discussed with the student, who should also sign the form. Please return this form to the student, who should file it in their portfolio, and retain a copy if you wish.

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PROFESSIONALISM ASSESSMENT FORM - SURGERYFeedback should be given to every student about their professionalism during their placement and upon completion of this form.

1 If you are unconcerned about a student’s professionalism, an overall assessment of “satisfactory” may be given without marking “satisfactory” on every criterion.

2 If you are concerned about a student’s professionalism, then three or more “cause for concern” or “unsatisfactory” in any category results in an overall assessment of “Unsatisfactory”.

3 Always decide and mark an overall “Satisfactory” or “Unsatisfactory” at the bottom of the form

4 Overall “Unsatisfactory” students are to be referred to their Academic Year Tutor

5 Please give full reasons for any “cause for concern” or “unsatisfactory” assessments on the reverse of this form

6 The student should make any responses on the reverse of this form

Student Name:

Placement: Year 5 SURGERY

Satisfactory Cause for Concern

Unsatisfactory Unable to Observe

1 Honesty and IntegrityAlways honest with patients, peers, staff in professional work (presentations, documentation, communication)

2 Reliability and Responsibility:Reliable and conscientious. Punctual. Completes assigned tasks. Accepts responsibility for errors.

3 Respect for Patients:Consistently demonstrates respect for patients’ autonomy and dignity. Maintains confidentiality at all times. Always appropriately dressed for clinical setting.

4 Respect for Others:Shows respect for patients’ relatives, other healthcare team professionals and members of staff

5 Attendance and Approach to Learning:Full attendance, participation at seminars and other learning opportunities

6 Compassion and Empathy:Listens attentively and responds humanely to patients’ and relatives concerns

7 Communication and Collaboration:Works co-operatively and communicates effectively with patients and healthcare team members

8 Self-Awareness and Knowledge of Limits:Recognises need for guidance and supervision, aware of appropriate professional boundaries. Personal beliefs do not prejudice approach to patients

9 Altruism and Advocacy:Adheres to the best interests of patients

10 Health:Does not allow his/her health or condition to put patients and others at riskOVERALL ASSESSMENT

PLEASE INDICATE IF THIS ASSESSMENT HAS BEEN DISCUSSED WITH THE STUDENT YES NO

TUTOR NAME

TUTOR SIGNATURE

DATE

PLEASE CONTINUE OVERLEAF IF NECESSARY

PROFESSIONALISM ASSESSMENT FORM (CONTINUED)

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Please give FULL reasons for any “Cause for Concern” or “Unsatisfactory” assessments here. You may also make any other comments.

TUTOR COMMENTS:

THE STUDENT MAY MAKE RESPONSES HERE

STUDENT SIGNATURE DATE

Completed forms to be returned to Mr Malcolm Fish, Student Office, Garrod Building, Whitechapel

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YEAR 5 ANAESTHESIA & CRITICAL CARE END OF PLACEMENT ASSESSMENT FORM

STUDENT NAME





Case summary and reflection (Surgery or ACC)

Clinical reasoning


Module activity form



PASS FAIL


NAME OF ASSESSOR



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PROFESSIONALISM ASSESSMENT FORM – ANAESTHESIA & CRITICAL CAREFeedback should be given to every student about their professionalism during their placement and upon completion of this form.







Student Name:

Placement: Year 5 SAPOC – ANAESTHETICS AND ITU


Unsatisfactory Unable to Observe












TUTOR NAME

TUTOR SIGNATURE

DATE

PLEASE CONTINUE OVERLEAF IF NECESSARY

PROFESSIONALISM ASSESSMENT FORM (CONTINUED)

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TUTOR COMMENTS:




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GENERAL INTERNAL MEDICINE (GIM) & EMERGENCY MEDICINE (EM)

Case-based discussion (CBD)Students are required to submit a CBD. This is designed to assess your clinical decision-making and the application or use of medical knowledge in relation to patient care of a particular patient for whom you have been responsible. Any fully registered medical practitioner (F2 or more senior) may conduct this assessment.

The CBD includes assessment of:1. Medical record keeping 2. Clinical assessment 3. Investigation and referrals4. Treatment 5. Follow-up and future planning6. Professionalism7. Overall clinical judgement

There is space on the form for you to write an action plan in response to your assessor’s comments.

Multi-source feedback (MSF)Students are required to submit 5 (MSF) forms collected during the six weeks spent on placement in GIM & EM. MSF is an assessment tool which allows you to collect opinions from people around you about your behaviour in the workplace. It is a good way of identifying areas for professional development.

Your assessors should include a range of people from your placement including consultants, GPs, other career grade doctors, doctors in training, nurses, therapists, pharmacists, ward clerks, administrators, secretaries & auxiliary staff.

You will be assessed on:1. Good clinical care2. Maintaining good medical practice3. Relationships with patients4. Working with colleagues

There is space on the form for you to write an action plan in response to each assessor’s comments.

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YEAR 5 CASE BASED DISCUSSION (CBD)

STUDENT NAME







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YEAR 5 GIM & EM - MULTI-SOURCE FEEDBACK FORM 1

STUDENT NAME






Please return a copy of this form to the student, who should file it in their portfolio, and retain a copy for your files.

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STUDENT NAME







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STUDENT NAME






Please return a copy of this form to the student, who should file it in their portfolio, and retain a copy for your files.YEAR 5 GIM & EM - MULTI-SOURCE FEEDBACK FORM 4

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STUDENT NAME







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STUDENT NAME







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YEAR 5 GENERAL INTERNAL MEDICINE END OF PLACEMENT ASSESSMENT FORM

STUDENT NAME





CBD (if complete, tick pass) Clinical reasoning




PASS FAIL


NAME OF ASSESSOR



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PROFESSIONALISM ASSESSMENT FORM – GIMFeedback should be given to every student about their professionalism during their placement and upon completion of this form.







Student Name:

Placement: Year 5 AMC – GIM


Unsatisfactory

Unable to Observe












TUTOR NAME

TUTOR SIGNATURE

DATE

PLEASE CONTINUE OVERLEAF IF NECESSARYPROFESSIONALISM ASSESSMENT FORM (CONTINUED)

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TUTOR COMMENTS:



COMPLETED FORMS TO BE RETURNED TO MR MALCOLM FISH, STUDENT OFFICE, GARROD BUILDING, WHITECHAPEL

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YEAR 5 EMERGENCY MEDICINE END OF PLACEMENT ASSESSMENT FORM

STUDENT NAME





CBD (if complete, tick pass) Clinical reasoning




PASS FAIL


NAME OF ASSESSOR



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PROFESSIONALISM ASSESSMENT FORM – EMFeedback should be given to every student about their professionalism during their placement and upon completion of this form.







Student Name:

Placement: Year 5 AMC – ED AND AM


Unsatisfactory

Unable to Observe












TUTOR NAME

TUTOR SIGNATURE

DATE

PLEASE CONTINUE OVERLEAF IF NECESSARYPROFESSIONALISM ASSESSMENT FORM (CONTINUED)

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TUTOR COMMENTS:




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OTHER ASSESSMENTS

There are many other mandatory elements of coursework which need to be completed satisfactorily over the course of year 5. The manner in which they are assessed, and the way in which those assessments are collated, is summarised below. Community careAssessment elements include:

Team working in primary care project Letter writing exercise Case summary and reflection 2 mini-CEX 2 end of placement assessments 2 professionalism assessment forms

Details and submission will be co-ordinated by CBME

Student selected components (SSC)Submission of SSC and elective reports will be on line and this process will be co-ordinated by Cat Allan in the student office on behalf of Dr NS Patel.

Prescribing Safety Assessment (PSA)In addition to the in house assessment elements listed in your logbooks, you will need to record a pass in one of the sittings of the national PSA. We will be informed of your results directly by the Medical Schools Council.

DATE, ILS, BBN & SIMSatisfactory completion of these four mandatory courses is mandatory. The course organisers will communicate directly with the student office on your behalf.

LogbookYour competence in performing the various clinical skills required by your curriculum and by the GMC in Tomorrow’s Doctors will be assessed by the practitioners supervising you over the year. You need to collect signatures from them in your logbook to provide evidence of your competence. At the end of your final clinical placement before Easter you will need to show your logbook to your supervising consultant for him/her to certify whether the evidence you have collected against the GMC mandated skills is complete. This should be recorded on page 13/14 which will be torn out and retained by the phase 3 team.

John BrecknellHead of MBBS Year 5

July 2015

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year 5 caf 2015 16 jb

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