SIU Department of Family and Community Medicine. PO Box 19671, Springfield, IL 62794-9671, 217-545-0200
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SITE VISIT CHECKLISTA Department of Family & Community Medicine medical student education faculty member will visit with the student and his/her preceptor, during the second week of the preceptorship, to ensure that the student is exposed to appropriate ambulatory and hospital experience. Below is a list of the areas that are reviewed with the student and preceptor.
 
 
Preceptor: ___________________________________________ Date: ________________

Student: _____________________________________________
INSTRUCTIONS: For each of the items listed below, either place a check mark in the space, if that item is being performed satisfactorily, or a "0" if it not being done. For some items, a number will be appropriate.
 
 
Physician's Teaching Style Comments
___Preceptor allows active student learning/work;  not shadowing: _________________________________________
___Student presents case to preceptor and formulates  management plan (more then H/P info) _________________________________________

___Physician then questions and comments		 _________________________________________

___Preceptor observes at least one complete exam and several focused parts		 _________________________________________

___Physician and student recheck patient together		 _________________________________________

___Student writes or dictates progress note		 _________________________________________

___Student writes SOAP notes (should write at least 10 notes for clerkship)		 _________________________________________

___Student writes prescriptions		 _________________________________________

___Office procedures performed by student		 _________________________________________

___Physician allows time for student to read		 _________________________________________

 
Physician's Practice Comments
___Night call (number of times per week) _________________________________________

___OB (number of deliveries per week)		 _________________________________________

___Gyne (percentage of practice)		 _________________________________________

___Peds (percentage of practice)		 _________________________________________

___Geriatrics (percentage of practice)		 _________________________________________

___Student examines 8-10 patients per day (not too many more)		 _________________________________________

___Hours/days in office daily		 _________________________________________

___% of time student spends w/ primary preceptor		 _________________________________________

___Nursing home visits (number made)		 _________________________________________

___Home visits (number made)		 _________________________________________

___Attends Family Practice business meetings (hospital, partner meeting, committees, etc.)		 _________________________________________

___Student attends a family conference or counseling session (if available)		 _________________________________________

 
Hospital Practice Comments
___Student admits at least three (3) patients per week _________________________________________

___Student follows at least three (3) patients per day in hospital		 _________________________________________

___Student does initial work-up and progress notes		 _________________________________________

___Student assists with procedures		 _________________________________________

___Student writes management plan in chart or on order sheet		 _________________________________________

___Student writes SOAP notes in chart		 _________________________________________

___Student writes/dictates discharge summary on at least one patient		 _________________________________________

___Student is allowed to leave clinic some but not too much to admit patients to the hospital		 _________________________________________

___Student examines patients in the ER and/or follows FP patient into surgery		 _________________________________________

 
Other Comments
___Student observes procedures on FP patients (i.e. x-rays, EMG, echo, etc.) _________________________________________

___Student works with other physicians or health care providers (i.e. PA, NP, etc.)		 _________________________________________

 
Student Comments
___Stays in community/commutes from home _________________________________________

___Accommodations are satisfactory		 _________________________________________

___Student seems to be happy and doing well		 _________________________________________

___Reminded of Health Care in the Community visit, EBM, which common problem, Read Sloane, Extra credit paper and return date, Social Gathering		 _________________________________________

___Call Room-Ask student if he/she has secure place to put belongings during the day		 _________________________________________

 
Student/Preceptor Comments
___Student/preceptor relationship is satisfactory _________________________________________

___Preceptor is happy with student's performance		 _________________________________________

___Preceptor reminded to complete mid-preceptorship evaluation and to give feedback to student		 _________________________________________


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