Year 5 Caf 2015 16 JB

COLLECTED ASSESSMENT FORMS
YEAR 5: 2015/2016
NAME
E-MAIL
The material collected in this document should be used together with the QMUL Academic
Regulations and the Student Guide. These are available at www.arcs.qmul.ac.uk. This
document provides information specific to Barts and The London School of Medicine and
Dentistry (SMD), while the Student Guide gives information common to all students of the
College. The Academic Regulations provide detailed information on all aspects of award
requirements and governance.
NOTHING
PRINTED
IN
THIS
DOCUMENT
OVERRIDES
REGULATIONS WHICH ALWAYS TAKE PRECEDENCE.
THE
ACADEMIC
Handbooks for each module of year 5, the scheme for assessment and all SMD policies and
regulations are available electronically on QM+
The information in this document was correct at the time of printing. In the event of any
substantial amendments to the information herein, the SMD will attempt to inform students
of the changes.
SMD cannot accept responsibility for the accuracy or reliability of
information given in third party publications or websites referred to in this handbook.
CONTENTS
Introduction
CAF submission checklist
Surgery & anaesthesia and critical care

MSF forms
ACC module activity form
Year 5 core element grading criteria
Surgery end of placement forms
ACC end of placement forms
4
5
11
12
13
16
General internal medicine & emergency medicine

CBD form
MSF forms
GIM end of placement forms
EM end of placement forms
19
20
21
26
29
Other assessments in year 5
32
___________________________________________________________________________________________________________________
YEAR 5 Collected Assessment Forms 2015/16
School of Medicine and Dentistry, QMUL
INTRODUCTION
This document is designed to provide in one place most of the assessment forms
you will need to have completed by supervising practitioners during the first
half of year 5. Guidance on what is expected of you is available in each
modules handbook and in the scheme for assessment for MBBS Part 5, both of
which are available on QM+. The Year 5 Student Logbook should be used day
to day on clinical placements to collect evidence of your progress towards
foundation level competence in the various clinical skills listed in Tomorrows
Doctors (GMC 2009).
The completed forms included here, as well as your logbook need to be submitted
to the Phase 3 team in the Student Office in the Garrod Building by 4pm on March
4th 2016. Please take and retain a copy of every submitted element. Use the
checklist below to help you remember everything. It will be signed and returned to
you as a receipt.
CAF SUBMISSION CHECKLIST

SURGERY & ANAESTHESIA AND CRITICAL CARE
1. ONE case summary + reflection
2. ONE ACC module activity form
3. FIVE multi-source feedback forms
4. TWO completed end of firm assessment sheets
5. TWO completed professionalism assessments
GENERAL INTERNAL MEDICINE & EMERGENCY MEDICINE
1. ONE case based discussion (CBD)
2. FIVE multi-source feedback forms
3. TWO completed end of firm assessment sheets
4. TWO completed professionalism assessments
OTHER DOCUMENTS
Year 5 logbook (you will continue to collect evidence of your progress within this
until the end of June 2016, but please submit it at this time. p13/14 will be
removed and the book returned to you)
FIRST NAME
LAST NAME
EMAIL
@qmul.ac.uk
Student Office Use Only
PRINT NAME (Staff)
SIGNATURE
DATE
SURGERY & ANAESTHETIA AND CRITICAL CARE

___________________________________________________________________________________________________________________
Multi-source feedback (MSF)

Students are required to submit 5 (MSF) forms collected during the six weeks spent
on placement in Surgery & Anaesthetics and ITU. MSF is an assessment tool which
allows you to collect opinions from people around you about your behaviour in the
workplace. It is a good way of identifying areas for professional development.
Your assessors should include a range of people from your placement including
consultants, GPs, other career grade doctors, doctors in training, nurses, therapists,
pharmacists, ward clerks, administrators, secretaries & auxiliary staff.
You will be assessed on:
1. Good clinical care
2. Maintaining good medical practice
3. Relationships with patients
4. Working with colleagues
There is space on the form for you to write an action plan in response to each
assessors comments.
Case summary & reflection
Please present your writing to your supervising consultant in either surgery or ACC.
It should not be longer than 2-sides of A4 and will be in two sections.
1. A summary of the patient in the form that would be used for handover to a
colleague. You should keep this to one paragraph
2. A reflective discussion section addressing principles of Good Medical Practice
(GMC 2013). You may wish to structure this second part as follows:
A short description - what happened; what am I looking at?
Interpretation what are the important or salient features?
Outcomes what have I learnt from this; how will this impact me in the
future?
Reflect on your own experiences as much as possible rather than observing others,
as this will improve your own self-awareness. The example you take should be an
interesting, difficult or uncomfortable experience. Try to record both positive and
negative elements. The important thing is that you demonstrate ability to reflect
and show what you have learnt from these experiences and can identify further
learning needs.
Please use the Helvetica or Verdana font, 11 point, single spacing
Module activity form Anaesthesia & Critical Care
Please record the clinical programme you follow over the three weeks together with
evidence of taking part in:
an on call period
a pre-assessment clinic
a pain ward round
an ICU case presentation
___________________________________________________________________________________________________________________
YEAR 5 SURGERY & ANAESTHESIA & CRITICAL CARE: MULTI-SOURCE

FEEDBACK FORM 1
STUDENT NAME
TEACHING HOSPITAL
DATES
GRADING SCALE AND FEEDBACK

1
Below expectations for a final year student
Borderline for a final year student
Meets the expectation for a final year student
Above the expectation for a final year student
UC
Please mark this if you have not observed the behaviour and therefore feel unable to comment
Please grade the following areas (please circle) using the above scale on the basis of your expectation of a final
year student ready to commence duties as a foundation year 1 trainee
GOOD CLINICAL CARE
Ability to diagnose patient problems
UC
Ability to formulate appropriate management plans
UC
Awareness of their own limitations
UC
Ability to respond to psychosocial aspects of illness
UC
Appropriate utilisation of resources e.g. shadow ordering of investigations
UC
Ability to manage time effectively and prioritise
UC
Technical skills (appropriate to current level)
UC
Relationships with patients
UC
Communication with patients
UC
Respect for patients and their right to confidentiality
UC
Verbal communication skills
UC
Written communication skills
UC
Ability to recognise and value the contribution of others
UC
Accessibility and reliability
UC
OVERALL
UC
MAINTAINING GOOD MEDICAL PRACTICE
RELATIONSHIPS WITH PATIENTS
WORKING WITH COLLEAGUES
Please use this box to comment on areas of excellence (please continue on reverse if necessary)
Please use this box to make suggestions for development (please continue on reverse if necessary)
Action plan (student to complete, please continue on reverse if necessary)
Please return this form to the student, who should file it in their portfolio, and
retain a copy if you wish.
___________________________________________________________________________________________________________________

FEEDBACK FORM 2
STUDENT NAME
TEACHING HOSPITAL
DATES

1
UC
GOOD CLINICAL CARE
UC
UC
UC
UC
UC
UC
UC
UC
UC
UC
UC
UC
UC
UC
OVERALL
UC
___________________________________________________________________________________________________________________

FEEDBACK FORM 3
STUDENT NAME
TEACHING HOSPITAL
DATES

1
UC
GOOD CLINICAL CARE
UC
UC
UC
UC
UC
UC
UC
UC
UC
UC
UC
UC
UC
UC
OVERALL
UC
___________________________________________________________________________________________________________________

FEEDBACK FORM 4
STUDENT NAME
TEACHING HOSPITAL
DATES

1
UC
GOOD CLINICAL CARE
UC
UC
UC
UC
UC
UC
UC
UC
UC
UC
UC
UC
UC
UC
OVERALL
UC
___________________________________________________________________________________________________________________

FEEDBACK FORM 5
STUDENT NAME
TEACHING HOSPITAL
DATES

1
UC
GOOD CLINICAL CARE
UC
UC
UC
UC
UC
UC
UC
UC
UC
UC
UC
UC
UC
UC
OVERALL
UC
___________________________________________________________________________________________________________________
10
YEAR 5 ANAESTHESIA & CRITICAL CARE;
Module Activity Summary

At the end of each day, please record your activity
Week 1
AM
PM
One thing I have learned today
Monday
Tuesday
Wednesday
SPORT
Thursday
Friday
Week 2
AM
PM
Monday
Tuesday
SPORT
Wednesday
Thursday
Friday
Week 3
AM
PM
Monday
Tuesday
Wednesday
SPORT
Thursday
Friday
On Call _____________________________________________________________________________
Signature and Date
Pain Ward Round ____________________________________________________________________

Signature and Date
ICU case Presentation ________________________________________________________________

Signature and Date
___________________________________________________________________________________________________________________
Module Sign Off:
Name and Signature
11
Nurse shadowing HDU/ICU ____________________________________________________________

Signature and Date
WORKSHEET (OPTIONAL)
Date__________________________________
Student_______________________________
Tutor_________________________________
Patient details:
Age, Gender, Ethnicity
ASA status
Presenting Problem
Anaesthetic challenge
Solutions?
ASA 1 A normal healthy patient

ASA 2 A patient with mild systemic disease
ASA3 A patient with severe systemic disease, that limits function, but is
not incapacitating.
ASA 4 A patient with severe systemic disease that is a constant threat to
life
ASA 5 A moribund patient who is not expected to survive without the
operation.
ASA 6 A declared brain-dead patient whose organs are being removed for
donor purposes.
Suffix E emergency procedure
___________________________________________________________________________________________________________________
12
3 things I have learned today

1
2
3
___________________________________________________________________________________________________________________
13
YEAR 5 CORE ELEMENT GRADING CRITERIA

The Assessor should award each student an overall assessment after consultation
with the appropriate tutors including junior members of staff who have been in
close contact with the student. Students should be assessed as individuals and all
students on a placement should only exceptionally receive the same assessment.
ATTRIBUTE
Attendance
PASS [P]
Good or acceptable record
Knowledge
Good or adequate knowledge

and satisfactorily able to relate
this to patient care.
Learns from experience.
Communication
Skills
Sound, caring attitude.

Takes time, listens and explains
well.
Competent and logical.
Usually complete, orderly and
systematic history and
examination.
Can elicit correct signs and
recognise most significant
findings.
Orderly and logical approach.
Clear and comprehensive
summary of patient case.
Clear and considered reflection.
Able to identify own learning and
further learning needs.
Able to discuss selected themes
with clinician in a thoughtful
manner.
Practical Skills
Case summary
and reflection
Clinical
reasoning
MSF
FAIL [F]
Poor record
Unexplained absences
Uninterested - does not read relevant
literature.
Fails to apply basic science to clinical
problems.
Unable to construct a differential
diagnosis with judgement.
Poor listener and communicator.
Explanations lack precision and
clarity.
Incomplete, inaccurate and poorly
recorded history and examination.
Lacks basic skills.
Poorly constructed summary.

Focuses only on biomedical aspects.
Does not cover professional practice
issues or has a superficial manner.
Unable to identify own learning and
further needs.
Unable to discuss selected themes
with a clinician in a thoughtful
manner.
Unable to analyse clinical information.
Jumps to premature and
inappropriate conclusions.
Able to use the information

obtained from history and
examination to construct a
differential diagnosis and
interrogate this by ordering
reasonable investigations.
Able to interpret investigations
to build towards a definitive
diagnosis.
Accepts uncertainty
Please discuss the students MSF forms with the student and make a
summary statement
___________________________________________________________________________________________________________________
14
YEAR 5 SURGERY END OF PLACEMENT ASSESSMENT FORM

STUDENT NAME
TEACHING HOSPITAL
DATES
Please refer to the year 5 core element grading criteria on page 12 for grading and feedback
instructions and tick the appropriate box below
PASS
FAIL
PASS
Attendance
Knowledge
Communication skills
Practical skills
Case summary and reflection

(Surgery or ACC)
Clinical reasoning
FAIL

synthesis
PROFESSIONALISM
Please complete the professionalism assessment form
OVERALL GRADE AWARDED PLEASE CIRCLE ONE OPTION ONLY
PASS
FAIL
Assessors general comments: Please comment on any favourable areas or any areas to which the student
should be asked to pay special attention and on any factors, which may have interfered with the learning of the
student. A COMMENT MUST BE ENTERED FOR ALL FAILED STUDENTS
NAME OF ASSESSOR
SIGNATURE OF ASSESSOR
DATE
Student Declaration
I have been absent from the attachment for the following number of days (including half days).
If you have NOT been absent please write 0
No. Days Absent
STUDENT SIGNATURE
DATE
The students performance should be discussed with the student, who should also
sign the form. Please return this form to the student, who should file it in their
portfolio, and retain a copy if you wish.
___________________________________________________________________________________________________________________
15
PROFESSIONALISM ASSESSMENT FORM - SURGERY

Feedback should be given to every student about their professionalism during their placement and upon completion
of this form.
1
If you are unconcerned about a students professionalism, an overall assessment of satisfactory may be given
without marking satisfactory on every criterion.
If you are concerned about a students professionalism, then three or more cause for concern or
unsatisfactory in any category results in an overall assessment of Unsatisfactory.
Always decide and mark an overall Satisfactory or Unsatisfactory at the bottom of the form
Overall Unsatisfactory students are to be referred to their Academic Year Tutor
Please give full reasons for any cause for concern or unsatisfactory assessments on the reverse of this form
The student should make any responses on the reverse of this form
Student Name:
Satisfactory
Cause for
Concern
Unsatisfactory
Unable to
Observe
Placement: Year 5 SURGERY

Honesty and Integrity
1
Always honest with patients, peers, staff in professional
work (presentations, documentation, communication)
Reliability and Responsibility:
2
Reliable and conscientious. Punctual. Completes
assigned tasks. Accepts responsibility for errors.
Respect for Patients:
3
Consistently demonstrates respect for patients
autonomy and dignity. Maintains confidentiality at all
times. Always appropriately dressed for clinical setting.
Respect for Others:
4
Shows respect for patients relatives, other healthcare
team professionals and members of staff
Attendance and Approach to Learning:
5
Full attendance, participation at seminars and other
learning opportunities
Compassion and Empathy:
6
Listens attentively and responds humanely to patients
and relatives concerns
Communication and Collaboration:
7
Works co-operatively and communicates effectively with
patients and healthcare team members
Self-Awareness and Knowledge of Limits:
8
Recognises need for guidance and supervision, aware of
appropriate professional boundaries. Personal beliefs do
not prejudice approach to patients
Altruism and Advocacy:
9
Adheres to the best interests of patients
Health:
10
Does not allow his/her health or condition to put
patients and others at risk
OVERALL ASSESSMENT
PLEASE INDICATE IF THIS ASSESSMENT HAS BEEN DISCUSSED WITH THE STUDENT
YES
TUTOR NAME
TUTOR SIGNATURE
DATE
PLEASE CONTINUE OVERLEAF IF NECESSARY
___________________________________________________________________________________________________________________
NO
16
PROFESSIONALISM ASSESSMENT FORM (CONTINUED)

Please give FULL reasons for any Cause for Concern or Unsatisfactory
assessments here. You may also make any other comments.
TUTOR COMMENTS:
THE STUDENT MAY MAKE RESPONSES HERE
STUDENT SIGNATURE
DATE
Completed forms to be returned to Mr Malcolm Fish, Student Office, Garrod

Building, Whitechapel
___________________________________________________________________________________________________________________
17
YEAR 5 ANAESTHESIA & CRITICAL CARE END OF PLACEMENT ASSESSMENT

FORM
STUDENT NAME
TEACHING HOSPITAL
DATES
PASS
FAIL
PASS
Attendance
Knowledge
Practical skills

(Surgery or ACC)
Clinical reasoning
PROFESSIONALISM
Module activity form
FAIL

synthesis

PASS
FAIL
NAME OF ASSESSOR
DATE
Student Declaration
No. Days Absent
STUDENT SIGNATURE
DATE
___________________________________________________________________________________________________________________
18
PROFESSIONALISM ASSESSMENT FORM ANAESTHESIA & CRITICAL CARE

of this form.
1
If you are unconcerned about a students professionalism, an overall assessment of satisfactory may be given
without marking satisfactory on every criterion.
Please give full reasons for any cause for concern or unsatisfactory assessments on the reverse of this form
Student Name:
Satisfactory
Cause for
Concern
Unsatisfactory
Unable to
Observe
Placement: Year 5 SAPOC ANAESTHETICS AND ITU

1
Always honest with patients, peers, staff in professional
work (presentations, documentation, communication)
2
3
times. Always appropriately dressed for clinical setting.
Respect for Others:
4
Shows respect for patients relatives, other healthcare
team professionals and members of staff
5
6
Listens attentively and responds humanely to patients
and relatives concerns
7
Works co-operatively and communicates effectively with
patients and healthcare team members
8
Recognises need for guidance and supervision, aware of
appropriate professional boundaries. Personal beliefs do
not prejudice approach to patients
9
Health:
10
OVERALL ASSESSMENT
YES
TUTOR NAME
TUTOR SIGNATURE
DATE
___________________________________________________________________________________________________________________
NO
19

TUTOR COMMENTS:
STUDENT SIGNATURE
DATE

___________________________________________________________________________________________________________________
20
GENERAL INTERNAL MEDICINE (GIM) & EMERGENCY MEDICINE (EM)

Case-based discussion (CBD)
Students are required to submit a CBD. This is designed to assess your clinical
decision-making and the application or use of medical knowledge in relation to
patient care of a particular patient for whom you have been responsible. Any fully
registered medical practitioner (F2 or more senior) may conduct this assessment.
The CBD includes assessment of:
1. Medical record keeping
2. Clinical assessment
3. Investigation and referrals
4. Treatment
5. Follow-up and future planning
6. Professionalism
7. Overall clinical judgement
There is space on the form for you to write an action plan in response to
your assessors comments.
Students are required to submit 5 (MSF) forms collected during the six weeks spent
on placement in GIM & EM. MSF is an assessment tool which allows you to collect
opinions from people around you about your behaviour in the workplace. It is a
good way of identifying areas for professional development.
Your assessors should include a range of people from your placement including
consultants, GPs, other career grade doctors, doctors in training, nurses, therapists,
pharmacists, ward clerks, administrators, secretaries & auxiliary staff.
You will be assessed on:
1. Good clinical care
2. Maintaining good medical practice
3. Relationships with patients
4. Working with colleagues
There is space on the form for you to write an action plan in response to
each assessors comments.
___________________________________________________________________________________________________________________
21
YEAR 5 CASE BASED DISCUSSION (CBD)

STUDENT NAME
TEACHING HOSPITAL
DATES

1
UC
GOOD CLINICAL CARE
UC
UC
UC
UC
UC
UC
UC
UC
UC
UC
UC
UC
UC
UC
OVERALL
UC
___________________________________________________________________________________________________________________
22
YEAR 5 GIM & EM - MULTI-SOURCE FEEDBACK FORM 1

STUDENT NAME
TEACHING HOSPITAL
DATES

1
UC
GOOD CLINICAL CARE
UC
UC
UC
UC
UC
UC
UC
UC
UC
UC
UC
UC
UC
UC
OVERALL
UC
Please return a copy of this form to the student, who should file it in their
portfolio, and retain a copy for your files.
___________________________________________________________________________________________________________________
23

STUDENT NAME
TEACHING HOSPITAL
DATES

1
UC
GOOD CLINICAL CARE
UC
UC
UC
UC
UC
UC
UC
UC
UC
UC
UC
UC
UC
UC
OVERALL
UC
___________________________________________________________________________________________________________________
24

STUDENT NAME
TEACHING HOSPITAL
DATES

1
UC
GOOD CLINICAL CARE
UC
UC
UC
UC
UC
UC
UC
UC
UC
UC
UC
UC
UC
UC
OVERALL
UC
___________________________________________________________________________________________________________________
25

STUDENT NAME
TEACHING HOSPITAL
DATES

1
UC
GOOD CLINICAL CARE
UC
UC
UC
UC
UC
UC
UC
UC
UC
UC
UC
UC
UC
UC
OVERALL
UC
___________________________________________________________________________________________________________________
26

STUDENT NAME
TEACHING HOSPITAL
DATES

1
UC
GOOD CLINICAL CARE
UC
UC
UC
UC
UC
UC
UC
UC
UC
UC
UC
UC
UC
UC
OVERALL
UC
___________________________________________________________________________________________________________________
27
YEAR 5 GENERAL INTERNAL MEDICINE END OF PLACEMENT ASSESSMENT

FORM
STUDENT NAME
TEACHING HOSPITAL
DATES
PASS
FAIL
PASS
Attendance
Knowledge
Practical skills
CBD (if complete, tick pass)
Clinical reasoning
FAIL

synthesis
PROFESSIONALISM
PASS
FAIL
NAME OF ASSESSOR
DATE
Student Declaration
No. Days Absent
STUDENT SIGNATURE
DATE
___________________________________________________________________________________________________________________
28
PROFESSIONALISM ASSESSMENT FORM GIM

of this form.
1
If you are unconcerned about a students professionalism, an overall assessment of satisfactory may be
given without marking satisfactory on every criterion.
Please give full reasons for any cause for concern or unsatisfactory assessments on the reverse of this
form
Student Name:
Satisfactory
Cause for
Concern
Unsatisfactory
Unable to
Observe
Placement: Year 5 AMC GIM

1
Always honest with patients, peers, staff in
professional work (presentations, documentation,
communication)
2
3
times. Always appropriately dressed for clinical
setting.
Respect for Others:
4
Shows respect for patients relatives, other
healthcare team professionals and members of staff
5
6
Listens attentively and responds humanely to
patients and relatives concerns
7
Works co-operatively and communicates effectively
with patients and healthcare team members
8
Recognises need for guidance and supervision, aware
of appropriate professional boundaries. Personal
beliefs do not prejudice approach to patients
9
Health:
10
OVERALL ASSESSMENT
YES
NO
TUTOR NAME
TUTOR SIGNATURE
DATE

___________________________________________________________________________________________________________________
29

TUTOR COMMENTS:
STUDENT SIGNATURE
DATE
COMPLETED FORMS TO BE RETURNED TO MR MALCOLM FISH, STUDENT

OFFICE, GARROD BUILDING, WHITECHAPEL
___________________________________________________________________________________________________________________
30
YEAR 5 EMERGENCY MEDICINE END OF PLACEMENT ASSESSMENT FORM

STUDENT NAME
TEACHING HOSPITAL
DATES
PASS
FAIL
PASS
Attendance
Knowledge
Practical skills
CBD (if complete, tick pass)
Clinical reasoning
FAIL

synthesis
PROFESSIONALISM
PASS
FAIL
NAME OF ASSESSOR
DATE
Student Declaration
No. Days Absent
STUDENT SIGNATURE
DATE
___________________________________________________________________________________________________________________
31
PROFESSIONALISM ASSESSMENT FORM EM

of this form.
1
If you are unconcerned about a students professionalism, an overall assessment of satisfactory may be
given without marking satisfactory on every criterion.
Please give full reasons for any cause for concern or unsatisfactory assessments on the reverse of this
form
Student Name:
Satisfactory
Cause for
Concern
Unsatisfactory
Unable to
Observe
Placement: Year 5 AMC ED AND AM

1
Always honest with patients, peers, staff in
professional work (presentations, documentation,
communication)
2
3
times. Always appropriately dressed for clinical
setting.
Respect for Others:
4
Shows respect for patients relatives, other
healthcare team professionals and members of staff
5
6
Listens attentively and responds humanely to
patients and relatives concerns
7
Works co-operatively and communicates effectively
with patients and healthcare team members
8
Recognises need for guidance and supervision, aware
of appropriate professional boundaries. Personal
beliefs do not prejudice approach to patients
9
Health:
10
OVERALL ASSESSMENT
YES
NO
TUTOR NAME
TUTOR SIGNATURE
DATE

___________________________________________________________________________________________________________________
32

TUTOR COMMENTS:
STUDENT SIGNATURE
DATE

___________________________________________________________________________________________________________________
33
OTHER ASSESSMENTS
There are many other mandatory elements of coursework which need to be
completed satisfactorily over the course of year 5. The manner in which they are
assessed, and the way in which those assessments are collated, is summarised
below.
Community care
Assessment elements include:
Team working in primary care project
Letter writing exercise
2 mini-CEX
2 end of placement assessments
2 professionalism assessment forms
Details and submission will be co-ordinated by CBME
Student selected components (SSC)
Submission of SSC and elective reports will be on line and this process will be coordinated by Cat Allan in the student office on behalf of Dr NS Patel.
Prescribing Safety Assessment (PSA)
In addition to the in house assessment elements listed in your logbooks, you will
need to record a pass in one of the sittings of the national PSA. We will be
informed of your results directly by the Medical Schools Council.
DATE, ILS, BBN & SIM
Satisfactory completion of these four mandatory courses is mandatory. The course
organisers will communicate directly with the student office on your behalf.
Logbook
Your competence in performing the various clinical skills required by your
curriculum and by the GMC in Tomorrows Doctors will be assessed by the
practitioners supervising you over the year. You need to collect signatures from
them in your logbook to provide evidence of your competence. At the end of your
final clinical placement before Easter you will need to show your logbook to your
supervising consultant for him/her to certify whether the evidence you have
collected against the GMC mandated skills is complete. This should be recorded on
page 13/14 which will be torn out and retained by the phase 3 team.
John Brecknell
Head of MBBS Year 5
July 2015
___________________________________________________________________________________________________________________

Year 5 Caf 2015 16 JB

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COLLECTED ASSESSMENT FORMS

CAF submission checklist

Surgery & anaesthesia and critical care

General internal medicine & emergency medicine

Other assessments in year 5

School of Medicine and Dentistry, QMUL

CAF SUBMISSION CHECKLIST

SURGERY & ANAESTHETIA AND CRITICAL CARE

School of Medicine and Dentistry, QMUL

Multi-source feedback (MSF)

School of Medicine and Dentistry, QMUL

YEAR 5 SURGERY & ANAESTHESIA & CRITICAL CARE: MULTI-SOURCE

GRADING SCALE AND FEEDBACK

Below expectations for a final year student

Borderline for a final year student

Meets the expectation for a final year student

Above the expectation for a final year student

Ability to formulate appropriate management plans

Awareness of their own limitations

Ability to respond to psychosocial aspects of illness

Appropriate utilisation of resources e.g. shadow ordering of investigations

Ability to manage time effectively and prioritise

Technical skills (appropriate to current level)

Relationships with patients

Communication with patients

Respect for patients and their right to confidentiality

Verbal communication skills

Written communication skills

Ability to recognise and value the contribution of others

Accessibility and reliability

MAINTAINING GOOD MEDICAL PRACTICE

RELATIONSHIPS WITH PATIENTS

WORKING WITH COLLEAGUES

Action plan (student to complete, please continue on reverse if necessary)

School of Medicine and Dentistry, QMUL

YEAR 5 SURGERY & ANAESTHESIA & CRITICAL CARE: MULTI-SOURCE

GRADING SCALE AND FEEDBACK

Below expectations for a final year student

Borderline for a final year student

Meets the expectation for a final year student

Above the expectation for a final year student

Ability to formulate appropriate management plans

Awareness of their own limitations

Ability to respond to psychosocial aspects of illness

Appropriate utilisation of resources e.g. shadow ordering of investigations

Ability to manage time effectively and prioritise

Technical skills (appropriate to current level)

Relationships with patients

Communication with patients

Respect for patients and their right to confidentiality

Verbal communication skills

Written communication skills

Ability to recognise and value the contribution of others

Accessibility and reliability

MAINTAINING GOOD MEDICAL PRACTICE

RELATIONSHIPS WITH PATIENTS

WORKING WITH COLLEAGUES

Action plan (student to complete, please continue on reverse if necessary)

School of Medicine and Dentistry, QMUL

YEAR 5 SURGERY & ANAESTHESIA & CRITICAL CARE: MULTI-SOURCE

GRADING SCALE AND FEEDBACK

Below expectations for a final year student

Borderline for a final year student