Step 1/15
Information
First name
Last name
Date of birth
Month
Day
Year
Email Address
Step 2/14
Learning Activity 1: Learning Contract
Student Learning Goals
Improve my history and physical exam skills.
Increase my understanding of family medicine specialty and practice management.
Improve my patient communication skills and clinical procedural skills.
Improve my record-keeping skills (use of EMR, SOAP notes, etc.)
Improve my knowledge of diagnoses and treatments and case presentation skills.
Other
If other, please specify.
Step 3/14
Learning Activity 1: Learning Contract
Student Strategies: (Please select up to 3 strategies for achieving your goals)
Be assertive in asking questions and clinically adaptive.
Participate in procedures that I’ve never done before.
Ask questions and read about the family medicine specialty(practice management, lifestyle, income, etc).
Be thorough in patient histories and physicals and develop differential diagnosis and treatment on my own.
Try to see a variety of patients (ages, conditions, genders).
Other
If other, please specify.
Step 4/14
Learning Activity 1: Learning Contract
Preceptor Strategies: (Please select 3 strategies for helping student achieve their goals)
Provide student with opportunities to see a variety of patients (ages, conditions, genders) and as many patients as possible.
Allow student to function as independently as possible and provide student with appropriate feedback on their performance.
Allow student to participate in clinical procedures (including observational).
Expose student to practice management learning opportunities (PCMH, EMR, billing, specialty referrals, etc.)
Preceptor Initials
Step 5/14
Learning Activity 2 & 3: Core Conditions
Online Documentation of Core Conditions (PxDx) New Innovations. Required PxDx documentation in New Innovations is due by midnight on the last day of the clerkship.
Completion of 12 corresponding MedU Cases on-line-(canvas)
Quiz 1
Quiz 2
Quiz 3
Step 6/14
Learning Activity 4: Prescription Writing Exercise
Completed and reviewed with preceptor/resident.
Preceptor/Resident Initials
Step 7/14
Learning Activity 5: Brief Intervention for Risky Health
Completed and reviewed with preceptor/resident.
Preceptor/Resident Initials
Step 8/14
Learning Activity 6: Patient Centered Medical Home
Patient Centered Medical Home Concept Assessed/Discussed with preceptor/resident or office manager.
Preceptor/Resident/Office Manager Initials
Step 9/14
Learning Activity 7: Clinical Care Guidelines
Recommendations for Primary Care Practice:
Visit Link
Completed and reviewed with preceptor/resident.
Preceptor/Resident Initials
Step 10/14
Learning Activity 8: Procedures
Please document 3 procedures performed (i.e. joint injection, punch biopsy, interpretation of EKG, microscopy of urine sample, vaginal smear, BP verification, etc.)
All procedures must be performed under direct supervision of a preceptor.
Select Procedure #1...
Arterial Line Placement
Biopsy of a skin lesion - excisoin
Biopsy of a skin lesion - shave
Biopsy of a skin lesion - punch
Central Line Placement
Chest Tube Placement
Colonoscopy
Colposcopy
Cryotherapy of a skin lesion
Endometrial Biopsy
First Assist on Cesarean Section
FSE/IUPC placement
Incision and Drainage of Abscess
Injection/aspiration of joint or bursa
IUD Placement
Lumbar Puncture (neonatal)
Manual Removal of the Placenta
Nasolaryngoscopy
Neonatal Circumcision
Pap smear
Paracentesis
Partial Toenail Removal
Perineal laceration repair - 3rd or 4th
Repair of Complex Laceration
Repair of Simple Laceration
Second Degree Laceration Repair
Skin tag removal
Thorecentesis
Trigger Point Injection
Vacuum Delivery
Vaginal Delivery, Vertex Presentation
Vasectomy
For student’s level of training procedure was performed in a manner that was:
Please select...
Below Expectations
Satisfactory
Exceeding Expectations
Preceptor Comment/Initials
Step 11/14
Learning Activity 8: Procedures
Select Procedure #2...
Arterial Line Placement
Biopsy of a skin lesion - excisoin
Biopsy of a skin lesion - shave
Biopsy of a skin lesion - punch
Central Line Placement
Chest Tube Placement
Colonoscopy
Colposcopy
Cryotherapy of a skin lesion
Endometrial Biopsy
First Assist on Cesarean Section
FSE/IUPC placement
Incision and Drainage of Abscess
Injection/aspiration of joint or bursa
IUD Placement
Lumbar Puncture (neonatal)
Manual Removal of the Placenta
Nasolaryngoscopy
Neonatal Circumcision
Pap smear
Paracentesis
Partial Toenail Removal
Perineal laceration repair - 3rd or 4th
Repair of Complex Laceration
Repair of Simple Laceration
Second Degree Laceration Repair
Skin tag removal
Thorecentesis
Trigger Point Injection
Vacuum Delivery
Vaginal Delivery, Vertex Presentation
Vasectomy
For student’s level of training procedure was performed in a manner that was:
Please select...
Below Expectations
Satisfactory
Exceeding Expectations
Preceptor Comment/Initials
Step 12/14
Learning Activity 8: Procedures
Select Procedure #3...
Arterial Line Placement
Biopsy of a skin lesion - excisoin
Biopsy of a skin lesion - shave
Biopsy of a skin lesion - punch
Central Line Placement
Chest Tube Placement
Colonoscopy
Colposcopy
Cryotherapy of a skin lesion
Endometrial Biopsy
First Assist on Cesarean Section
FSE/IUPC placement
Incision and Drainage of Abscess
Injection/aspiration of joint or bursa
IUD Placement
Lumbar Puncture (neonatal)
Manual Removal of the Placenta
Nasolaryngoscopy
Neonatal Circumcision
Pap smear
Paracentesis
Partial Toenail Removal
Perineal laceration repair - 3rd or 4th
Repair of Complex Laceration
Repair of Simple Laceration
Second Degree Laceration Repair
Skin tag removal
Thorecentesis
Trigger Point Injection
Vacuum Delivery
Vaginal Delivery, Vertex Presentation
Vasectomy
For student’s level of training procedure was performed in a manner that was:
Please select...
Below Expectations
Satisfactory
Exceeding Expectations
Preceptor Comment/Initials
Step 13/14
Learning Activity 9 & 10: Comprehensive History and Physical & Progress/Clinical Encounter Notes
For student’s level of training History and Physical documentation is:
Please select...
Below Expectations
Satisfactory
Exceeding Expectations
Preceptor Comment/Initials
Two Clinical Encounter Notes:
1. SOAP Format
1. C/S Format
2. SOAP Format
2. C/S Format
For student’s level of training, the SOAP notes are: (please note: C/S format is for self-study)
Please select...
Below Expectations
Satisfactory
Exceeding Expectations
Preceptor Comment/Initials
Step 14/14
Almost done!
Select Faculty Evaluator...
Wafa Algahmi, MD
Halima Ali, MD
Carol Baker, MD
Michelle Diebold, MD
Tyler Drewry, MD
Nobin Kottukapally, MD
Elizabeth Lewan, DO
Karen Weaver, MD
Scott Yaekle, MD
Nicholus Yee, MD
Chin Yi, MD
Mid-Clerkship Evaluation was submitted.
Clerkship/Hospice Debriefing Session attended (4th Wednesday afternoon of clerkship).
Student Evaluation of the FM Clerkship - completed in New Innovations.
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