NAME :

SPECIALTY : HOSPITAL :
CRITERIA POOR DEFICIENT SATISFACTORY GOOD EXCELLENT COMMENTS
A. Clinical skills
History taking
Physical exam
Clinical Acuity
- Investigations
-Diagnosis
- Judgement
Operative skill
After care
B. Knowledge
Basic Science
Clinical
C. Postgraduate Activities
Teaching
Lecturing style
Case presentation
Presentations
Research ability and audit
D. Attitudes
Reliability
Self motivation
Leadership
Administration
CLINICAL REPORT FORM (SPECIALISTS)
Clinical Report Form - Specialists Page 1 of 2
CRITERIA POOR DEFICIENT SATISFACTORY GOOD EXCELLENT COMMENTS
D. Attitudes
Relationships with:
a. Colleagues
b. Patients
c. Other staff
E. Contribution
Current service
Involvement in regional
activities
Future Plans
SUPERVISOR/HEAD OF DEPARTMENT SIGNATURE(S) and NAME in block capitals:
DATE:
SUPERVISOR/HEAD OF DEPARTMENT FUTHER COMMENTS :
F. Extra Qualities
CHAIRMAN OF M19 PROMOTION COMMITTEE COMMENTS:
Clinical Report Form - Specialists Page 2 of 2