YL9 RATING SCALE FOR PERFORMANCE

(SKILLS)

Date: _______________________ Name of Intern: _________________________________

Rotation: ____________________Hospital: _______________________________________
Procedure: ____________________________________________________________________

Lowest Highest

Made sure that the correct procedure was being done to

0 0.25 0.5 0.75 1 1.25 1.5 1.75 2
the correct patient at the correct site

Maintained good rapport with the patient, including

making an effort to put the patient at ease and to 0 0.25 0.5 0.75 1 1.25 1.5 1.75 2
minimize discomfort and pain

Paid meticulous attention to basic asepsis and antisepsis

0 0.25 0.5 0.75 1 1.25 1.5 1.75 2
techniques

Paid strict and meticulous attention to basic surgical /

0 0.25 0.5 0.75 1 1.25 1.5 1.75 2
procedural techniques throughout the procedure

Correctly used the proper instruments during the entire

0 0.25 0.5 0.75 1 1.25 1.5 1.75 2
procedure

FINAL SCORE

Consultant’s Signature ________________________________

Consultant’s Name ________________________________
 YL9 RATING SCALE FOR PROFESSIONALISM

Date: _______________________ Name of Intern: _________________________________

Rotation: ____________________Hospital: _______________________________________

Lowest Highest
Has good working relationship with other team
0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0
members, enhances the value of the team

Shows proper respect for patients, peers, faculty, and

0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0
allied health personnel

Shows sensitivity and compassion to patient’s culture,

0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0
age, gender, and disabilities

Maintains honesty and integrity at all times 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0

Demonstrates a commitment to ethical principles

(confidentiality of patient information, informed
0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0
consent, provision or withholding of clinical care, and
business practices)

Demonstrates initiative and a desire for excellence 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0

Accepts limitations and failings, open to feedback and

0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0
criticism, shows desire for self-improvement

Maintains a professional demeanor in manner, dress and

0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0
action, and excludes self-confidence

Demonstrates organizational ability, responsibility,

0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0
dependability

Punctual and complete attendance 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0

FINAL SCORE

Evaluator’s Signature ________________________________

Evaluator’s Name ________________________________
Evaluator’s Position Consultant
Resident
Faculty
 YL9 FOR CLINICAL PERFORMANCE EVALUATION FORM

Date: _______________________ Name of Intern: _________________________________

Rotation: ____________________Hospital: _______________________________________
Topic: ____________________________________________________________________

Lowest Highest
Did the intern carry out a rational diagnostic approach? <=5 6 7 8 9 10 11 12
• Obtained pertinent data and also sought to exclude other possible
diagnosis
• Obtained accurate and complete history in a logical manner
• Performed a complete and systematic physical exam
Did the intern describe the patient’s clinical manifestations clearly, concisely <=5 6 7 8 9 10 11
and accurately?
Did the intern arrive at a good clinical impression? <=8 9 10 11 12 13 14 15 16
• Was the intern able to recognize salient features and correlate data
to make a diagnosis?
Did the intern rule in/out pertinent and plausible differential diagnosis? <=5 6 7 8 9 10 11
• Did the intern recommend / request appropriate tests?
• Was the intern able to rationalize the use of such test?
Was the intern able to explain the underlying pathophysiology of the 1 2 3 4 5 6
patient’s illness?
Was the intern able to discuss / suggest / carry out a rational and appropriate <=8 9 10 11 12 13 14 15 16
treatment plan for the patients?
Was the intern able to analyze the patient’s clinical course / response to <=5 6 7 8 9 10 11
treatment?
Was the intern able to explain appropriate preventive health care measures <=5 6 7 8 9 10 11
that may be recommended to the patient and family?
Was the intern able to make a concise yet fairly complete contextual analysis 1 2 3 4 5 6
of the patient’s over-all biologic, physchologic, socioeconomic, and spiritual
status?
FINAL SCORE

Consultant’s Signature ________________________________

Consultant’s Name ________________________________