MCSO/OSU-CHS

ANESTHESIA

NAME OF RESIDENT *

Rotation Dates

Month *

Year *

Name of evaluator *

Lichert Scale 1=poor 3=average 5=excellent

CORE COMPETENCY EVALUATION

Did the intern / resident demonstrate Osteopathic Skills during this rotation? *

Did the Intern/Resident demonstrate adequate medical knowledge during this rotation? *

Did the intern / resident demonstrate professionalism during this rotation? *

Did the Intern / Resident demonstrate adequate interpersonal and communication skills during this rotation? *

Did the Intern / Resident demonstrate adequate patient care skills for their level of training? *

Did the Intern demonstrate adequate use of resource materials during this rotation? *

Did the Intern / Resident demonstrate punctuality? *

ROTATION SPECIFIC QUESTIONS *

	1	2	3	4	5	UE
Ability to use mask ventilation	1	2	3	4	5	UE
Ability to perform endotracheal intubation	1	2	3	4	5	UE
Placement of peripheral IV	1	2	3	4	5	UE
Placement of central lines	1	2	3	4	5	UE
Knowledge of pharmacology of anesthia	1	2	3	4	5	UE
Understands emergency airway management	1	2	3	4	5	UE
Basic use of anesthesia machine	1	2	3	4	5	UE

ROTATION SPECIFIC COMMENTS

Comments * 🛈

Signature of Evaluator *

UPIN

SSN

MCSO ID MCSO ID

Date: *