ICU Workplace-Based Assessment Form - GENERAL Name of Trainee: Initiated assessment: ☐ # ICU months: (Months of ICU rotation completed since beginning of CCM program) Name of Faculty: Initiated assessment: ☐ Date: MM / DD / YY Setting: ☐ ICU ☐ E.R. ☐ Ward ☐ Post-Op Unit EPA: ☐ Resuscitation ☐ New Consultation ☐ Multidisciplinary Rounds Type of assessment: ☐ Direct Observation Clinical activity directly observed by supervisor in real clinical setting. ☐ Case Review Clinical activity retrospectively reviewed partially or fully by supervisor. ☐ Simulation Clinical activity directly observed by supervisor in simulation setting. Complexity: ☐ Low Routine clinical problem, presentation, and management. ☐ Moderate Some elements of complexity in clinical problem, presentation, and management. ☐ High Complex and atypical clinical problem, presentation, and management. Brief case description: CHOOSE 2 AREAS OF FEEDBACK. For each, provide: 1) narrative comments on trainee's strengths, areas for development, and improvement strategies, and 2) choose a level of autonomy on the entrustment scale. NEEDS INTERVENTIONS Unable to do without others’ actions. NEEDS DIRECTIONS Partially able to do with others’ directions. NEEDS MINIMAL GUIDANCE Mostly able to do with minimal guidance. AUTONOMOUS Able to do without guidance; refinement possible with feedback. EXPERT Able to do in complex situations; personal insight on performance. Areas of feedback Feedback ☐ Initial Stabilization Normalizing the vital signs of an unstable patient through appropriate and timely actions. Narrative Comments INTERVENTION ☐ DIRECTION ☐ GUIDANCE ☐ AUTONOMOUS ☐ EXPERT ☐ ☐ Clinical Assessment Gathering comprehensive and/or relevant information required for the elaboration of a diagnosis. Narrative Comments INTERVENTION ☐ DIRECTION ☐ GUIDANCE ☐ AUTONOMOUS ☐ EXPERT ☐ ☐ Diagnosis Generating differential, working, and definitive diagnoses on available clinical information. Narrative Comments INTERVENTION ☐ DIRECTION ☐ GUIDANCE ☐ AUTONOMOUS ☐ EXPERT ☐ ☐ Management / Clinical Judgment Making adequate decisions and taking appropriate actions when dealing with medical problems. Narrative Comments INTERVENTION ☐ DIRECTION ☐ GUIDANCE ☐ AUTONOMOUS ☐ EXPERT ☐ ☐ Communication Narrative Comments
Communicating clearly and efficiently with patients, families, colleagues, healthcare team. INTERVENTION ☐ DIRECTION ☐ GUIDANCE ☐ AUTONOMOUS ☐ EXPERT ☐ ☐ Organization / Efficiency Delivering care with optimal use of time and resources. Narrative Comments INTERVENTION ☐ DIRECTION ☐ GUIDANCE ☐ AUTONOMOUS ☐ EXPERT ☐ ☐ Documentation Comprehensive, concise and meaningful record keeping. Narrative Comments INTERVENTION ☐ DIRECTION ☐ GUIDANCE ☐ AUTONOMOUS ☐ EXPERT ☐ ☐ Professionalism Commitment to high standards of behavior and ethics. Narrative Comments INTERVENTION ☐ DIRECTION ☐ GUIDANCE ☐ AUTONOMOUS ☐ EXPERT ☐ ☐ Insight Recognition of the limits of one's experience and expertise. Narrative Comments INTERVENTION ☐ DIRECTION ☐ GUIDANCE ☐ AUTONOMOUS ☐ EXPERT ☐ OVERALL PERFORMANCE Choose a level of autonomy on the entrustment scale for the overall clinical activity being assessed. NEEDS INTERVENTIONS Unable to do without others’ actions. ☐ NEEDS DIRECTIONS Partially able to do with others’ directions. ☐ NEEDS MINIMAL GUIDANCE Mostly able to do with minimal guidance. ☐ AUTONOMOUS Able to do without guidance; refinement possible with feedback. ☐ EXPERT Able to do in complex situations; personal insight on performance. ☐ CanMEDS Roles Choose the role(s) addressed during the feedback. Medical Expert ☐ Communicator ☐ Collaborator ☐ Leader ☐ Health Advocate ☐ Scholar ☐ Professional ☐ Trainees' Comments/Reflections: Signatures: Trainee Faculty