CORAZON LOCSIN MONTELIBANO MEMORIAL REGloNAL HOSPITAL

Department of Health

Needs Falr/ A;NF!rae/e/ Good/ Excellent/

lmprovement/F(ardyl Infrequently(2points) MeetsExpectations(3points) Frequently(4points) Always(5points)
DOMAINS

. PSYCHIATRY Inadequate(1polnt)

Management Leadership

/
Facilitates development of organizational and leadership
traits
Demonstrates accountability and responsibility in
performance of duty
/
Demonstrates knowledge of the organizational structure and
key persons/individual
/
Exhibits pctsitive collaboration with other departments/units /
Subtotal:
(Total points + 4)
Teaching:
Exhibits a positive attitude in training students/clerks/interns /
Enthusiastic working with and learning from colleagues /
Takes time in teaching students/clerks/interns /
Subtotal:
(Total points + 3)
Schedule:
Always available to the assigned schedule of activity /
Subtotal:

Grand Total:
( Subtotal points +7)

Scoring,

4.21 -5.00 -~ Outstanding 2.61 -3.40 --Satisfactory

3.41 -4.20 --Very satisfactory 1.81 -2.60 --unsatisfactory

What were the strengths of this learning experience?

Being able to maximize my learnings in just a small amount of time.

What were the weakness of this learmng experience?

Not being able to grasp everything in just a month

Whatsuggestionscanyou maketo improvethislearningexperience? I

Keep up the good work.

CLINICAL CLERKS EVALUATION OF PRECEPTOR

CME,F,003
Iss[ic`d: 5/ 15/2018

Issue no. . 003 Page 2 ol` 2

 CORAZON LOCSIN MONTELIBANO MEMORIAL REGIONAL HOSPITAL
Department of Health

Clinical Clerks Evaluation of Preceptor

DR. CHERRYL FRANCIA PSYCHIATRY

Clinical Faculty/ Preceptor: __________________ Department: _________________
Borres, Monique T____________
Evaluated by: ___________
JULY 1-14, 2023
Evaluation Period: ______________
(Print Name and Signature] (Rotation Dates)

Instruction: This preceptor evoluotion is to be completed by the student towards the end of the rotation using the following scale below. Each evaluation srotement includes
examples of defining characteristics far the item.

Needs Fair/ Average/ Good/ Excellent/

Improvement Infrequently Meets Frequently Always
AREAS OF EVALUATION
/Rarely/ Expectations
Inadequate
(lpoint) (2 points) (3 points) (4 points) (5 points)
Knowledge Integration:
Associates Pathophysiology with points condition /
Requests appropriate diagnostic procedure/exam /
Implements communication and interprets therapeutic /
treatments or procedures
. Subtotal:
(Total points-:- 3)
Communication:
Exhibits very good communication skills /
Actively listens and encourages questions /
Provide constructive criticism or feedback /
Promotes positive interpersonal relationship /
Subtotal:
(Total points-:- 4)
Critical Thinking:
Demonstrates excellent clinical reasoning skills /
Demonstrates organizational skills to achieve maximum /
efficiency
Always follows evidence-based in management of patients /
Subtotal:
(Total points-:- 3)
Human Caring:
Exhibits care and compassion in dealing with patients /
Respects cultural, ethical, legal, religious rights of patients /
Exhibits professionalism in dealing with fellow government /
workers, patient's family and colleagues.
Subtotal:
(Total points-:- 3)

C'LINIC-AL CLERKS EVALUATION OF PRECEPTOR

CME.F.003
Issued: 5; I 5!�01 R
Issue 1w. : 003
 CORAZON LOCSIN MONTELIBANO MEMORIAL REGIONAL HOSPITAL
enent § ten - Control of Documents

Document Review, A|)I)roval, [ssuance & Retrieval Recoi.d (DRAIRR)

A. ISSUE NulvIBER : B.DOCUMENT TYPE tick box
I Manual I Standard Operating Procedure
ER::sion I Policy t21 Form/ Checklist
• New Code? Fa No [Yes (specfty) I Work Instruction I Others (speclfy)
• Describe changes:
1. Change of template and format, retained contents of previoli§ issue.
2. "Areas of evaluation" total are divided per row/ detail ( /3. /4. /3. /3, /4, /3)
• Processes affected? F21 NOE Yes ( specify org group/ process):
1.

C. Mark "X" if
Doc# DOCUMENT TITLE : Doc DOCUMENT CODE: ol)so[ete (for DC)

1) Clinical clerks Evaluation of preceptor 1} CME.F.003

E. REVIEW & APPROVAL: NAME & POSITION I SIGNATURE DATE lssuE DATE
PREPARED BY:
Clemente A. Dizon Ill, RN •s/.{l,i AY 1 5 2

-\,
Administrative Officer I, CMETRU
EFFECTIVITYDATE
Carmelo C. Canto, MD
REVIEWED BY:
Continuing Medical Education. Training and Research Officer 5/'o`18
Marlon L. Tabligan, MD
APPROVED BY:
QMR/CMF'S AY 1 1 20 8MAY 2 4

F. ISSUANCE (filled u bv coDv holder) ! I. OBSouETE RETRIEVAL (filled uD bv retriever)

Name and Position of Signature of JDoc.#
Org. Group Issued Date Received Date Reti.ieved Retrieved By
Recipient Recipient
Cwh\''i +<,4Y\e- On`wl rha2OTtro,at,Q]an"*Cintw}«

-I. MAY 1 5 2 18

DRAmFORM
CLhAI\4RII-DC.F.008
I§sued: 7/1 7/14
Issue No.: 001 Page I
 CORAZON LOCSIN "ONTELIBANO MEMORIAL REGIONAL HOSPITAL
ement S stem - Control of Documents

Document Dissemination Form (I)DF)

DOcllMENT TITLE : f,I,iu`cAi cLetlKS EVAw,arliow oF Pnecepmri
DOCUMENT CODE: C,ME . f=. Ot'?
lssuE NUIVIBER: Oo?
PROCESS OWNER: CM€iY,u
DISSEMINATION DATE: 5 I 15 I IR

-
AFFIXING YOUR SIGNATURE MEANS YOU FULLY UNDERSTOOD THE DISSEIVIINATED INFORMATION

1.
2.
CM47manh
NAME

in,2A:thrA
IAn^/a
At,A~
Th
^7Aori'i^'Le,
wl-
ORGANIZATIONAL GROUP

.
SIGNATURE

` . `. -. j!.I.`,I-..;

3. Iquttw u"t}6 ^rtasih- " whrmi TZFLW - o`

4. BORRES, MONIQUE T. PSYCHIATRY DEPARTMENT I

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DDFFORM
CLMrmll-DC.F.0o6
Issued: 7/22/15
Issue No.: 001 Page I